Journa

Susan Hyde, DDS, MPH,

PhD, FACD, andDick Gregory, DDS

Times change, but our promises remain the same.

The Dentists Insurance Company (TDIC) is proud to celebrate 35

years dedicated to protecting dentists. We thank you for helping usreach this milestone through your ongoing support of our company.The promises we made in 1980 are still true today: to only protectdentists, to protect them better than any other insurance companyand to be there when they need us.We look forward to celebrating new milestones with you as wecontinue to strengthen, innovate and grow. Thank you.

439 Root Caries in Older Adults

Root caries is a major cause of tooth loss in older adults and the need for improvedpreventive efforts and treatment strategies for this population is acute.Dick Gregory, DDS, and Susan Hyde, DDS, MPH, PhD, FACD

447 Aging Periodontium, Aging Patient: Current Concepts

This paper presents the current state of knowledge and opinion on approaches toperiodontal diseases and periodontal treatment in the elderly with an emphasis onconsensus, conclusions and future directions for dental practitioners.Mark Ryder, DMD

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Volume 43, Number 8

August 2015

DIRECTOR

Journal of the California Dental Association (ISSN 1043-2256) is published monthly by theCalifornia Dental Association, 1201 K St., 14th Floor, Sacramento, CA 95814, 916.554.5950.Periodicals postage paid at Sacramento, Calif. Postmaster: Send address changes to Journalof the California Dental Association, P.O. Box 13749, Sacramento, CA 95853.The California Dental Association holds the copyright for all articles and artwork publishedherein. The Journal of the California Dental Association is published under the supervision ofCDAs editorial sta. Neither the editorial sta, the editor, nor the association are responsible forany expression of opinion or statement of fact, all of which are published solely on the authorityof the author whose name is indicated. The association reserves the right to illustrate, reduce,revise or reject any manuscript submitted. Articles are considered for publication on conditionthat they are contributed solely to the Journal.Copyright 2015 by the California Dental Association. All rights reserved.

GuestEditorEditor

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Collaborative Practice Paving the Path to Success

Susan Hyde, DDS, MPH, PhD, FACD

any Native American

cultures teach thatcaring for elders is ablessing path in whichthe whole communityshould participate. Like many of us withaging parents, I have provided a lot ofcare to my parents, and oral health issuesalways arose. My experiences dealingwith my fathers care-resistant behaviorsas he battled Alzheimers and difficultiesin obtaining dental treatment for mystepmother, who was paralyzed andunable to speak as the result of a stroke,contributed greatly to my decision tospecialize in geriatric dentistry. Thanksto the geriatric training I received,when my mother moved into a longterm care facility, I immediately put heron a three-month schedule for homevisits with a dental hygienist. Similarly,when my father-in-laws face balloonedbecause of multiple periapical abscesses,I was able to raise the awareness of hisfamily, endocrinologist and orthopedicsurgeon that the needed dental treatmentwasnt elective but rather critical to theresolution of his poor wound-healingfrom a recent diabetic amputation. Myexperiences are by no means unique.Homebound and institutionalized olderadults lack access to dental care andendure a great deal of untreated oraldisease, which affects their abilities toeat and socialize, resulting in furthercompromised overall health and function.1Beginning with the Surgeon GeneralsReport on Oral Health in America,through 15 years of compelling researchpublications and two seminal Institute ofMedicine reports on oral health, dentistryhas achieved national recognitionthat oral health is necessary for overallhealth. For the first time, access to

Inclusion of oral-systemic health data in risk

dental care is one of the Leading Health

Indicators for Healthy People 2020.2Additionally, oral health disparities inolder adults are now recognized to extendbeyond edentulism, as reflected by thenew Healthy People 2020 objectivesto reduce untreated coronal and rootcaries in older adults, and decreasethe prevalence of moderate or severeperiodontal disease.3 Therefore, primarycare providers must obtain training in oralhealth screening and referral, consideroral health in disease management andcollaborate with the dental communityto develop home-based programsfor older adults in order to achievepatient-centered, value-based care.1An article in the October 2014 issueof the Journal of the California DentalAssociation described the NationalInterprofessional Initiative on OralHealth (NIIOH), established in 2008 tolaunch a new standard of care for patientoral health.4 The initiative espousedprimary care providers becoming skilledat addressing the oral health needs oftheir patients and effectively referringto dentists. The traditional head, ears,eyes, nose and throat (HEENT) physicalassessment performed by primary careproviders excludes examination of theoral cavity and omits consideration oforal-systemic linkages to overall health.Incorporating the oral cavity into a revisedHEENOT examination affirms that oral

health is an important population health

issue for primary care providers.5 NewYork University has successfully integratedHEENOT in the comprehensive historyand physical examinations for nursingand medical student clinics and facultypractices. Inclusion of oral-systemichealth data in risk assessment and diseasemanagement plans have resulted inimproved collaboration and referralsbetween dental-primary care providers.6Dentists and dental hygienists alsoneed to participate in the cycle ofinterprofessional collaborative practice.Healthy People 2020 objectives promotecollaborative practice with two new oralhealth goals for increasing the proportionof adults who receive tobacco cessationinformation and who are tested or referredfor glycemic control by a dentist or dentalhygienist.3 Although previous studiesindicated both dentists and patients arereceptive to screening and managingmedical conditions in the dentalsetting,7,8,9 a survey of North Carolinadentists expressed reservations for takinga more active role in the managementof patients systemic conditions throughrisk behavior counseling, referral forlaboratory testing or in-office diagnosticscreening for medical conditions.10 REFERENCES

Susan Hyde, DDS, MPH, PhD,

FACD, chairs the division of oralepidemiology and dental public healthat the University of California, SanFrancisco, School of Dentistry. She is thedental director of UCSFs multidisciplinaryfellowship in geriatrics and faculty leadfor interprofessional ed ucation for theSchool of Dentistry. Dr. Hyde receivedher dental degree from UCSF, Master ofPublic Health and doctorate of philosophy(epidemiology) from the University ofCalifornia, Berkeley, and certificates in dentalpublic health and geriatrics from UCSF.

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Autonomy and Agency

David W. Chambers, EdM, MBA, PhD

The nub:1. Respect for autonomy isnice, but a bit paternalisticbecause either party alonecan make that determination.2. Dentists and adult patientsand nonpatients are agents,with the capacity to aecteach other.3. Morality requires that thesame moral status as agentsbe accorded all concerned.

David W. Chambers, EdM, MBA, PhD, is professor

of dental education at the University of the Pacic, ArthurA. Dugoni School of Dentistry, San Francisco, and editorof the Journal of the American College of Dentists.

Yogi Berra had it right: If the people dont want to

come, nothing can stop them. They are autonomous,in the literal sense of the term self-governing.Dentistry is one of the professions that has made quitea bit out of this principle. Patients get to choose even if the choices are limited for their own good.Bioethicists ground informed consent in the normof respect for autonomy. Sometimes informed consent ismistaken for a legal process. Sometimes it means littlemore than making certain patients have a generallyfavorable idea what is going to happen to them.Respect for autonomy is an ethical pillar in most professions.It just makes sense that when the professional sets up the groundrules, patients should be allowed the opportunity to opt out.But this is only half the story. What if we looked at itfrom the perspective of potential patients? It is plausible, ifa bit uncomfortable, for others to set their own conditionson whether or how they will participate (or not) in healthcare. This is a free choice and involves no necessary prejudiceagainst the professional, even if it means a hit to prestige,income, lost time and a ding on the self-concept of servingthe public. Others show respect for autonomy by notforcing conformity. Respect for autonomy loses some ofits nobility unless we accept that it works both ways.Agency is a sturdier moral concept. Agents have thecapacity and responsibility to affect others by their actions.Both dentists and patients are agents. Patients are agentswhen they refuse radiographs, choose less-than-idealtreatment to remain within the limits of their insurancecoverage or decide not to go to the dentist at all.Each dentist choice affects both the patient and thedentist; each patient choice affects both the dentist and thepatient. Dentists and patients are (potentially) reciprocalmoral agents. The challenge is to find a common way forwardthat neither party would have any reason to change.In the traditional approach to ethics, dentists consideronly what they understand to be in patients best interestsand claim the moral high ground by reluctantly allowingthem to elect less than ideal care. The dentists interestshave been screened off from consideration as not belongingto the sphere of professional ethics. Not so, of course, forpatients who judge their own and the dentists advantage.Morality requires more than one person deciding whetherhe or she has done right by private standards. Professionalsjustify their standards by roughly conforming to what theircolleagues are doing. Morality requires that agents recognizethe valid claim of other moral agents to affect them. A U G U S T 2 015 419

Practice SupportEmployment Practices

Fig uring out

sick leave isg ivin g me aheadache. Can Ihave a day off ?When it comes to employment practices, CDA members cannd some relief. Get assistance with every nuance of runninga practice through CDA Practice Support. From the facts onCalifornias new paid sick leave law to customizable employeemanual templates to help creating alternative work schedules,weve got it all. Whats more, if you need personalized advice,our employment expert is always just a phone call away.CDA Practice Support, its where smart dentists get smarter.800.232.7645 or cda.org/sickleave

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Cigarettes Linked to Half of Oral Cancer Deaths

Oral Surgery and

Anticoagulant TherapyResearchers recently assessed theincidence of postoperative bleeding inpatients who were highly anticoagulatedand in patients who underwent extensiveoral surgical procedures and who continuedusing oral anticoagulant therapy. Publishedin The Journal of the American DentalAssociation, the study found that, inpatients who are highly or therapeuticallyanticoagulated, dental extractions aswell as more extensive oral surgicalprocedures can be performed safely withoutinterruption or modification of the therapy.According to a summary of theresearch, the authors divided 125 patientsreceiving anticoagulant therapy intothree groups. Group A consisted of 54patients who were highly anticoagulated(international normalized ratio (INR) 3.5) and who had three teeth extracted.For Group B, the authors stated thatthis group consisted of 60 patients withINR 2.0 to less than 3.5 in whom higherrisk dentoalveolar surgery (extractionof more than three teeth or other oralsurgery procedure involving raisinga mucoperiosteal flap, osteotomy orbiopsy) was performed. Lastly, GroupC consisted of 11 patients whose INRvalues were 3.5 or higher and whorequired higher-risk dentoalveolarsurgery, and 85 healthy participants who422A U G U S T

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In 2011, there were more than 8,500 deaths in the U.S. from cancersof the oral cavity and pharynx. A recent study, published in JAMA InternalMedicine, estimated the number of deaths attributable to cigarette smokingfor 12 smoking-related cancers and found that, among U.S. adults 35 yearsand older in 2011, almost half (47 percent) of the deaths caused by cancersof the oral cavity and pharynx were attributable to cigarette smoking.Additionally, in the multi-institution research letter, the authors report thatthe overall number of deaths from 12 smoking-related cancers was nearly346,000. Of those, 48.5 percent were attributable to cigarette smoking.Specically, the researchers linked smoking with 80.2 percent of lung,bronchus and trachea cancer deaths, as well as 76.6 percent of deaths fromcancer of the larynx. Secondhand smoke exposure, which was estimated bythe 2014 U.S. Surgeon Generals report to cause an additional 5 percentof lung cancer deaths, was not included in the analysis.In the research letter, the authors stated that 44.8percent of bladder cancer deaths, 19.6 percent ofstomach cancer deaths and 22.2 percent of cervicalcancer deaths were linked to smoking.For more details and specicbreakdowns within each category, seethe full report published online aheadof print in the journal JAMA InternalMedicine, June 15, 2015.

underwent surgical procedures similar

to those performed in Group A andGroup B made up the control group.The authors reported that 3.7percent of Group A, 5 percent ofGroup B and 18.2 percent of Group Cexperienced postoperative bleeding,while a single bleeding event (1.2percent) occurred in the controlgroup. They concluded that dentalextractions in patients who are highlyor therapeutically anticoagulated could

be performed safely without interruption

or modification of the therapy.Tooth extractions and even moreextensive surgical procedures canbe performed safely in patients whocontinue using anticoagulant therapyif proper local hemostatic measures areused and if no other coagulopathiesare present, the authors wrote.For more, see the study in The Journalof the American Dental Association, June2015, vol. 146, issue 6, pp. 375381.

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Nanostructures in Dentin Make Teeth Crack Resistant

A team of international researchersrecently analyzed the complex structureof dentin and discovered that the mineralparticles are precompressed. The internalstress works against crack propagation andincreases resistance of the biostructure.According to the study, published inthe journal Nano Letters, the researchersused in-situ stress experiments andexamined the local orientation of themineral nanoparticles. They discoveredthat when the tiny collagen fibersshrink, the attached mineral particles

become increasingly compressed.

Our group was able to useratechanges in humidity to demonstratehow stress appears in the minerall in thesky,collagen fibers, said Paul Zaslansky,Dr. med. dent., PhD, a researcherr atase.Charit Berlin, in the news release.The compressed state helps toprevents cracks from developing andwe found that compression takess placein such a way that cracks cannot easilyreach the tooth inner parts, whichcould damage the sensitive pulp.

Four Out of 10 Pregnant Women Not

Seeing Dentist During PregnancyWhile the importance of oral health during pregnancyhas been shown, a new survey out recently has foundthat 42.5 percent of expecting mothers in the UnitedStates arent visiting a dentist during their pregnancy.According to a news release about a recent dentalinsurance survey, visiting the dentist during pregnancyis a crucial step and can help identify key health issuesappearing specically during pregnancy. Additionally,the California Dental Association says improving oralhealth during pregnancy can prevent complicationsassociated with dental diseases, may reduce pretermand low birth weight deliveries and has the potentialto prevent early childhood cavities in infants.It is important for women who are pregnant orplanning to become pregnant to visit a dentist for routineexamination, cleanings and guidance about specicoral health issues that may occur during pregnancy.For more information, see the June and September2010 issues of the Journal, available at cda.org/journal.

The scientists also analyzed what

happens if the tight mineral-proteinlink is destroyed by heating. Theyfound that, in that case, dentin inteeth becomes much weaker.We therefore believe that thebalance of stresses between the particlesand the protein is important for theextended survival of teeth in the mouth,said scientist Jean-Baptiste Forien.According to the authors, their findingsmay help explain why artificial toothreplacements usually do not work as wellas healthy teeth do they are simplytoo passive, lacking the mechanismsfound in the natural tooth structures, andconsequently fillings cannot sustain thestresses in the mouth as well as teeth do.Our results might inspire thedevelopment of tougher ceramicstructures for tooth repair orreplacement, Zaslansky said.For more information, see the studypublished in the journal Nano Letters,May 2015, vol. 15:6, pp. 3729-373.Illustration shows complex biostructure of dentin: Thedental tubuli (yellow hollow cylinders, diameters appr.1 micrometer) are surrounded by layers of mineralizedcollagen bers (brown rods). The tiny mineral nanoparticles are embedded in the mesh of collagen bers andnot visible here. Image: JB Forien @ CharitA U G U S T 2 015 423

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Dental Implants in Osteoporotic Women

Families of Orofacial Clefting,

No Higher Risk for DentalAnomaliesChildren with oral clefts showa wide range of dental anomalies,adding complexity to understandingthe phenotypic spectrum of orofacialclefting. In a recent study, researcherscharacterized the spectrum of cleft-relateddental anomalies and evaluated whetherfamilies with clefting have a significantlyhigher risk for such anomalies comparedto the general population. They foundthat families of orofacial clefting arenot at higher risk for dental anomalies.Published in the Journal of DentalResearch, the study included 3,811individuals 660 cases with clefts,1,922 unaffected relatives and 1,229controls. Researchers identified dentalanomalies from in-person dental examsor intraoral photographs and case-controldifferences were tested. This is thelargest international cohort to date ofchildren with nonsyndromic clefts, theirrelatives and controls, according to a newrelease. The authors report that cases hadhigher rates of dental anomalies in themaxillary arch than controls for primaryand permanent dentitions but not in themandible. They also reported findingdental anomalies were more prevalentin cleft lip with cleft palate than othercleft types and that more anomalieswere seen on the same side of the cleft.424A U G U S T

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With age, postmenopausal women with osteoporosis are at greater risk of losingtheir teeth. In a new study, researchers from Case Western Reserve University Schoolof Dental Medicine suggest dental implants may provide postmenopausal womenwith osteoporosis with the highest degree of satisfaction in their work and social lives.This investigation was initiated to incorporate oral health into womens healthpromotion and to examine psychosocial outcomes associated with dental implantsupported rehabilitation, the authors wrote.In the study, researchers surveyed 237 osteoporotic women with one or moreadjacent teeth missing. The survey consisted of 23 questions rating their satisfactionwith replacement teeth and how it improved their lives at work and in socialsituations specically in regards to the work, health, emotional and sexualaspects of their lives. Of the 237 participants, 64 had implant retained prostheticrestorations, 60 had traditional xed partial dentures, 47 had removable partialdenture and 66 had no restoration to restore missing teeth. No signicantdierence in age exists between groups, according to the study.The authors found that women with dental implants reported a higher overallsatisfaction with their lives, according to lead researcher Christine DeBaz, whopersonally interviewed each participant. Fixed dentures scored next highest insatisfaction, followed by false teeth and then women with no restoration work.In order to make decisions about the mostappropriate treatment option in rehabilitation a dentistmust understand not only the prosthetic therapeuticspecics such as chewing function and orofacial estheticsbut also the patient-centered specics of psychosocialand overall well-being, the authors wrote.For more, see the study in the International Journalof Dentistry, vol. 2015, article ID 451923, 6 pages.

Compared to controls, unaffected

siblings and parents showed a trend forincreased anomalies of the maxillarypermanent dentition. Yet, thesedifferences were nonsignificant aftermultiple-testing correction, suggestinggenetic heterogeneity in some familiescarrying susceptibility to both overtclefts and dental anomalies.Collectively, the findings suggestthat most affected families do not have

higher genetic risk for dental anomalies

than the general population and thatthe higher prevalence of anomaliesin cases is primarily a physicalconsequence of the cleft and surgicalinterventions, the authors concluded.For more information, see the studytitled Spectrum of Dental Phenotypesin Nonsyndromic Orofacial Clefting,published online first in the Journalof Dental Research, June 16, 2015.

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Weight-Related Risk Factor for Periodontitis

According to the Centers for DiseaseControl and Prevention, more than90 percent of adults aged 20-64 haveexperienced tooth decay and one in everythree adults is obese. In a recent systematicreview, authors indicate that obesity maybe one of a number of weight-related riskfactors for development of periodontitis.

In the new study, the authors note

that previous reviews were primarilybased on cross-sectional studies, withonly a few longitudinal or interventionstudies included. For their study, theresearchers examined the timedependent association between obesityand periodontitis and how changes

Porcine Collagen Barrier Aids Bone Regrowth

Researchers examined a new type of barrier membrane, calledporcine collagen, to nd out how quickly a bone graft can develop withthis material placed over the grafted tooth socket. While they found boneregeneration varied, the authors reported that porcine collagen showedpotential for promoting new bone growth.The study, which was published in the Journal of Oral Implantology,included 14 patients with a diagnosis of one or more unsalvageableteeth and a treatment plan to replace them with implant-supported singlecrown restorations. After the teeth were removed, the sockets were lledwith particulate allograft bone and covered with a layer of porcinecollagen. According to the study, the porcine collagen membranes werecut to overlap the facial and lingual (or palatal) socket rim by at least 5mm (or more if necessary) to cover bony wall fenestration or dehiscencedefects. Sixteen weeks later, researchers checked the sites and dentalimplants were placed.The formation of new bone in the treated sites averaged 11.2 percent,with a range of 1.8 percent to 43 percent, in bone biopsies trephined fromthe center of the grafted socket sites, the authors explained in the report.The authors concluded that The resulting new bone regeneration variedwidely, but the barrier membranes showed potentialalfor promoting signicant bone regeneration.They suggest a larger sample of treated casesis needed to support their conclusion.For more on this study, see the Journalof Oral Implantology, June 2015, vol. 41,no. 3, pp. 293297.

in weight may affect the development

and progression of periodontitis in thegeneral population. Searching studieswith overweight or obesity as exposureand periodontitis as outcome, theauthors reviewed eight longitudinaland five intervention studies thatassessed the association amongoverweight, obesity, weight gain, waistcircumference and periodontitis.Two of the longitudinal studies founda direct association between degree ofoverweight at baseline and subsequent riskof developing periodontitis, and a furtherthree studies found a direct associationbetween obesity and development ofperiodontitis among adults, the authorssummarized. Additionally, they found thattwo of the reviewed intervention studieson the influence of obesity on periodontaltreatment effects showed that the responseto nonsurgical periodontal treatment wasbetter among lean than obese patientswhile the remaining three studiesdid not report treatment differencesbetween obese and lean patients.In conclusion, the authors statedthat their systematic review suggestsoverweight, obesity, weight gain andincreased waist circumference may be riskfactors for development of periodontitisor worsening of periodontal measures.For more, see the study in theJournal of Periodontology, June 2015,vol. 86, no. 6, pp. 766-776.A U G U S T 2 015 425

Dick Gregory, DDS, is

the San Mateo Centerdirector for Apple TreeDental. He completedhis dental degree at theUniversity of California,Los Angeles, School ofDentistry in 1980 and atwo-year postgraduatemultidisciplinary geriatricfellowship at the Universityof California, San Franciscoin 2014. During theintervening three decades,he cared for his patientswhile in private generaldental practice in NorthernCalifornia.Conict of InterestDisclosure: None reported.

n this second of two issues

dedicated to the oral health ofolder adults, the Journal presentspossible resources for generaldentists to consider when caringfor older adults. Iain A. Pretty, BDS,MSC, MPH, PhD, FDSRCS(ED),writes about the Seattle CarePathway, which takes intoaccount the continuum of clinicalpresentation of older adults, with theresultant need for dentists to provideoral health anticipatory guidancefor patients, and if appropriate,their caregivers, as well as increasedcommunication with primary careproviders when developing careplans. Mark Ryder, DMD, reviewsthe roles of systemic disease,pharmacological management,immune response and functionalcapacity in the development andprogression of periodontal disease

that supports a collaborative practice

approach to treatment decisions.Guest editors Dick Gregory, DDS,and Susan Hyde, DDS, MPH, PhD,FACD, present alternative treatmentsfor root caries that could be deliveredbedside, such as silver diamine fluoridecariostasis, partial caries removal andglass ionomer restorations. DeborahJacobi, RDH, MA, and Michael J.Helgeson, DDS, write about Apple TreeDental, a community collaborativepractice model, that will soon beproviding comprehensive care tovulnerable populations in the BayArea and may become a statewidemodel for delivering on-site dentalservices within long-term care facilities.Finally, the contributing authors to theJuly and August issues of the Journalhave provided a national resourcesection of organizations and websitesdedicated to the care of older adults. A U G U S T 2 015 427

You are the reason people stand tall in front of the class,grin widely for the camera and never cover their mouthsin shame. You are the champion of the smile and all thepossibility it represents. The confidence you instill in yourpatients is one reason why CDA supports and protectsyour profession. Because the world is a better placewhen people are smiling, and thats thanks to you.

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seat tle care pathway

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The Seattle Care Pathway:

A B S T R A C T It is well-recognized that the demographic shift in the population will

result in a larger proportion of older adults and those adults will live longer than everbefore. There is, therefore, a need to ensure dental services recognize this transitionand plan for the management of older adults in primary care dental practices. Thisarticle describes the evidence for, and the details of, the Seattle Care Pathway toensure older adults receive optimum dental care.

AUTHOR

ACKNOWLEDGEMENT

Iain Pretty, BDS, MSC,

MPH, PhD, FDSRCS(ED),is a professor of publichealth dentistry at theUniversity of ManchesterSchool of Dentistry andco-director of ColgatePalmolives DentalHealth Unit, a 45-yearcollaboration between thecompany and the university.Dr. Pretty is workingon caries managementprograms for older peopleand, with internationalcolleagues, developed theSeattle Care Pathway, anevidence-based approachto assessing and planningthe oral care of olderpeople.Conict of InterestDisclosure: None reported.

n 2013, a group of interested

academicians, clinicians andpractitioners gathered in Seattle todiscuss the issues surrounding thedental care of older adults. Manyrecognized that while research wasavailable, it was difficult to consumeand there was little advice for dentalpractitioners on how to managethis increasing proportion of theirpopulation. In an effort to provide suchguidance, the Seattle Care Pathway forSecuring Oral Health in Older Patientswas produced. Readers can accessall 12 papers, including the pathwaydocument1 itself, free of charge fromthe Gerodontology website simplysearch for Seattle Care PathwayGerodontology online. The purposeof this article is to summarize the keyfindings of the conference in a singlesource that is accessible and relevantto general dental practitioners.

The ShiftThere is no doubt Western countriesare all experiencing a demographic shift a change in the population profilethat will see a greater proportion of olderadults who will be living longer thanever before.2,3 Such a shift has a profoundimpact on many aspects of society, notleast the financial considerations, butperhaps, one of the biggest concernsis maintaining the health and wellbeing of an aging population in aneconomically viable manner that doesnot destabilize health care systems.4Many could argue the shift is a perfectstorm older individuals with greaterand more complex health care needsbut no workplace medical insurancewill strain health care systems whileat the same time the proportion ofworking-age, tax-contributing individualsreduces. The obvious solution to theseissues would seem to be that preventionA U G U S T 2 015 429

Drivers for vulnerability

General health, presence of chronicdiseases,activities of daily living (ADL),performance, medication, burden,deprivation, access to services, luck.

Vulnerable

Population 1Population 2Population 3Line of vulnerability

ServicesPoorly dened, often highly variable, evenwithin health care systems. Poor access toservices and service specications basedon the treatment aspirations of youngeradults rather than directed by the oralhealth needs of the elder patients.ResearchEvidence base is poorer, fewerrecommendations based on clinical trialevidence, often focused on settings ratherthan delivery.

FIGURE . Life course and health.

is key. If individuals can be helped to

keep healthy for longer, and if chronic,debilitating diseases can be prevented,then the burden on health and socialcare systems can be reduced, quality oflife increased and the system maintained.Such an approach requires adifferent contextual framework for thedelivery of health care services andresources. The FIGURE demonstratesa life course model of health care.We can consider this model for anyaspect of health care, and dentistry isno exception. The three lines in themodel represent three hypotheticalindividuals or populations:430A U G U S T

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Population 1. The first population is

our ideal, the life course we hope for ourfamilies and ourselves. It is an individualborn above a line of vulnerability,who leads a long and healthy life and,toward the end of life, suffers someloss of function but remains vital andwith a good sense of well-being.Population 2. The second line is aworst-case scenario and perhaps seentoday in those individuals born withlife-threatening and altering conditionsthat cause severe disability and requireconstant medical attention and assistance.Such patients are likely to be managedby specialists in secondary care facilities.

Population 3. The third line is

perhaps the most reflective of theWestern population experience. Weare born and are vulnerable for aperiod of time, and then, fortunately,spend the majority of our lives fitand well, but with an end of lifethat may be affected by chronicconditions, loss of cognitive abilityand other factors that impact qualityof life and make us increasinglydependent and vulnerable.2What we know from dental andmedical attendance and resourceallocation research is the vast majorityof resource is spent on the middle

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TABLE 1

Dental Challenges of the Older Adult

Tooth loss

While now far less common, incremental loss of teeth leading to the decision to render an individual edentulous is still a major challenge formany older adults. The provision of complete prostheses is becoming more complex as patients typically lose their teeth at an older age andhave a reduced ability to cope with the challenges of managing a prosthesis.

Dental caries

Perhaps the most common challenge, in community-dwelling older adults, caries rates are similar to those in young children at about onesurface per year. While root caries are often considered the major issue in this age group, this appears to be largely a disease of adultsin residential and nursing homes, with coronal caries remaining the site of increment for older adults. Those in nursing homes will typicallyexperience a caries increment rate double that of their community-dwelling peers.

Periodontitis

A highly prevalent condition in this cohort of patients but with most attachment loss being in the form of gingival recession rather thanincreases in probing depth. The concept of health survivors is apropos here with teeth that remain into old age likely resilient toperiodontal disease. The changes in the immune system also contribute to the altered progression of the disease in this group, although thismust be set against the reduced ability to undertake some oral hygiene procedures that require ne motor skills.

Dry mouth

Both xerostomia and salivary gland hypofunction are seen in older patients, either together or alone, and can have a devastating impact.Caries risk is increased either due to loss of the protective saliva or due to measures taken to stimulate salivary ow (often sucking candies),and dry mouth is associated with a decrease in quality of life, diculty eating and wearing a prosthesis. Dry mouth is often associated withpolypharmacy.

Oral cancer/Precancer

Epidemiological data are scarce, but oral cancer and its precursors are generally seen in older populations and rates vary across developedand developing nations. Given its devastating impact, however, clinicians should be vigilant for oral lesions in all patients, especially thosewith recognized risk factors.

Access

Many older adults nd it increasingly dicult to access care. This may be due to transport, cognitive ability or their own general health andmobility. Dental oces may not cater well to wheelchair users or may not be located close to public transport links. In patient surveys, theneed to maintain access to dental care is often raised as older adults No. 1 concern with respect to their oral health.

Setting

Older adults living in nursing and residential care may be especially dicult to treat, especially if they cannot be easily transported to aregular clinical setting. The need for mobile dental units and sta is clear but the provision of these is often sporadic.

Resources

For many adults, dental insurance ceases or is reduced at retirement and, combined with a lower overall income level, resources becomescarce. This is confounded by the fact that many of these patients will have received complex dental treatments that may require additionalresource to maintain and protect.

section of this life course with some

(increasing) emphasis on youngchildren (those younger than age 3)and very little on end-of-life care.5It should be noted that the lifecourse makes no reference to anindividuals age. While it is clearindividuals are aging, placing artificialand arbitrary chronological metrics isnot helpful. We all know the 95-yearold man who we see out jogging andwe all, sadly, know of the 55-yearold man who has suffered a strokeand is unable to walk. We mustconsider our patients as individualsand plan their care appropriately.2

Dentistry and Vulnerability

The FIGURE also defines the currentposition of dental services, resources andresearch. While this is a generalization,it is largely applicable to all Westernhealth care models. For young children,there is a wealth of services, strongclinical trial evidence upon whichto base such services and, generally,the political, social and professionalwill to see oral health care improve.The reasons for poor oral health inyoung children are well understood,as are the means on individual andpopulation levels to address them. Thisis not to assert there is no longer an

issue in childrens oral health, but the

environment for change is present.2Looking at the older population, weare not in the presence of such clarity.The reasons for poor oral health are morecomplex, more interlinked and not aswell understood. There is little robustclinical trial evidence that has examinedthese populations in detail and it is oftennecessary to extrapolate from studiesundertaken on adolescents or children.Services are poorly defined, difficult toaccess and often restricted, for example,to older adults living in residential care.It is important to remember that whilethe media will often depict or reportA U G U S T 2 015 431

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TABLE 2

Definitions of Dependency Used in the Seattle Care Pathway

on the elderly living in nursing homes

less than 5 percent of older adults inWestern populations are in such housing the vast majority is communitydwelling, living either with caregivers(often partners) or on their own.Speaking to older people, theirpartners and caregivers, and thirdsector organizations, the medical termssurrounding aging are often foundto be pejorative, for example, frailty.Instead, the concept of dependency, orindeed independency, was recognizedas a more acceptable means of definingindividuals as they age. This is importantfor dentistry where we have the meansof implementing prevention at an earlystage to ensure that disease processescan be arrested or even reversed. In thecontext of the older adult, plans for thisapproach need to be undertaken early ina time best described as predependent.

Dental Challenges of Older Adults

These are well-described in amultitude of publications and weresummarized by Thompson in his Seattleconference presentation3 and shown inTA BLE 1 . The major dental issues facedby older people are broadly the sameas those of younger individuals. Manydentists are surprised, however, to learnthe caries increment in older adults isthe same as in younger children, aboutone surface increment per year, and,often surprising, too, is that this is mainlyin coronal surfaces.6 Root caries, oftenthought of as the major challenge of theelderly, is a disease entity largely confinedto those in residential and nursing care.7Tooth loss is typically an incrementalprocess that tends to occur throughout lifeand is more common than edentulism.Predicting it can be complex, and itsimpact on the remaining dentition, theprovision of prosthesis and its effecton quality of life can be substantial.8432A U G U S T

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No dependency

Fit, robust people who exercise regularly and are in the most t group fortheir age.

Predependency

People with chronic systemic conditions, which could impact on oral healththat, at point of the presentation, are not currently impacting on oral health.A comorbidity whose symptoms are well-controlled.

Low dependency

People with identied chronic conditions that are aecting oral health butwho currently receive or do not require help to access dental services ormaintain oral health. These patients are not frankly dependent, but theirdisease symptoms are aecting them.

Mediumdependency

People with an identied chronic system condition that currently impacts on

oral health and who receive or do not require help to access dental servicesor maintain oral health. This category would include patients who demand tobe seen at home or who do not have transport to a dental clinic.

High dependency

People with complex medical problems preventing them from going to receivedental care at a dental clinic. They dier from patients categorized in mediumdependency because they cannot be moved and must be seen at home.

Periodontal disease is complex from

an epidemiological position, not leastbecause of the multitude of definitions,indices and reporting mechanisms. Agingwas traditionally considered a risk factorfor periodontal disease, but the researchevidence is not clear.3 Longitudinal studiessuggest there is both a progression andremission of the disease process over timeand in older adults, attachment loss isoften the result of gingival recession ratherthan increases in periodontal pocketdepth.9 Nonetheless, plaque control andthe presence of florid, plaque-relatedmarginal gingivitis is often seen in olderadults, especially those with cognitive ormotor impairments.10 There is a conceptof healthy survivors, i.e., those teethpresent in older adults may be, for avariety of reasons, less susceptible tothe disease and hence the overall riskof progression is reduced. Those teeththat were susceptible will have beenlost through incremental extraction.Dry mouth is often cited as aconsequence of age that is exacerbated bypolypharmacy and other disease processes.Remembering that xerostomia is thesubjective feeling of dry mouth, whereas

salivary gland hypofunction results in low

salivary flow rate, both can be a threat tooral health and quality of life. Those withlow salivary flow rates have reduced salivarybuffering and remineralization abilitiesand those with xerostomia will often seekto reduce symptoms by sucking on sourcandies or something similar that providesa source of fermentable carbohydratesand, therefore, increased caries risk.Oral precancer and cancer is also adisease associated with older adults withcatastrophic consequences for thoseaffected. The ability to detect precancerouslesions early, confirm diagnosis andcommence treatment (including risk factorreduction) is key to positive outcomes.11

Meeting the Challenges: A Pathway

ApproachPathways were originally developed inindustry, particularly Japanese automobileproduction lines, where there was a focuson clearly defined steps that resulted ina consistent and predictable outcome.12The adoption of care pathways inmedicine has been rapid over recentyears and they aim to collate bestevidence and present this to clinicians

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in a supportive way so practitioners have

a more efficient and predictable meansof treating patients. The care pathwayrepresents a journey one that maybe paused, for example, while specialisttests are conducted or a caregiver isconsulted, or one that may be deviatedfrom if clinical experience dictates it.It is a journey that can be modifiedbased on local, regional and nationallyavailable guidance and resources.13Pathways should therefore be viewedas enablers documents or processesthat assist in clinical decision makingand, if followed correctly, can result in apredictable outcome as well as providingsupport for a clinicians approach to aparticular patient presentation. Thefull Seattle Care Pathway consideredindividuals, populations, treatments,prevention and communication issuesfor varying levels of dependency rangingfrom no dependency through highdependency. The dependency categorieswere described as shown in TA BLE 2 1 andthe care pathway in full in TA BLE 3 .These dependency categories weredeveloped to ensure critical elementswithin the life course could be captured.They were also felt to be tippingpoints when approaches to care wouldchange. All but the highest level ofdependency may represent patientsseen in community dental practice. Asthe definitions were discussed, manyin the group could identify these withtheir own patients or family members.Once the categories of patients weredetermined, the evidence base aroundtheir prevention and treatment optionscould be collated. The pathway documentwas presented in tabular form with themain supporting evidence provided.1Throughout the development of theguidance, the authors worked on the basisof dependency rather than a particularchronological age. However, it was clear

the implicit rationale behind the work was

older patients, and it became clear therehad to be a trigger age, an age at whichpatients should be considered against thepathway to ensure a change in dependencywas not missed. An age of 55 years wasagreed upon, with the assumption that atthis chronological time point almost everypatient would be in the nondependentcategory. Despite this stated triggerpoint, dentists should remain vigilant tothe onset of dependency at any age.1

Implementing the Pathway

The care pathway describes theassessment, preventive regime, treatmentand communication recommendationsfor each level of dependency (TA B L E 3 ).While the table is designed to be easy toimplement and understand, the authorsof the pathway determined that clinicalvignettes or examples might help theapplication. A series of examples wereincluded in the article and some furthercase scenarios, looking at no, pre- andmedium dependency, are described here.The purpose is to place the pathway intoreal-life context for dental practitioners,considering those patients who are mostlikely to present.

No DependencyThese are older individuals who are fitand exercise regularly. An example of thistype of patient might be the following:Arnold is a 75-year-old who livesat home with his wife and three dogs.He exercises regularly and is activelyinvolved in dog training for new dogowners in his community. He attendssix-month recalls at your practiceand three-month cleanings with yourhygienist. When you review his chart,the last treatment you provided wasa replacement restoration two yearsago. He is on a statin for cholesterolbut otherwise is on no medication.

One of the comments raised in the

conference was that this group wascommonly seen in general practice,but often fell off the radar, meaningthey began to fail to attend and beforelong were lost to the practice. This wasrecognized as an important place tostart considering the impact of aging.For this group, the importance is tostart the conversation about what mayhappen in the future. How can we keepin touch in case things change? It wasagreed that complex treatment plansin this group were not contraindicatedbut a conversation about implicationson the maintenance of such treatmentsshould things change was important.These groups need, as all patientsdo, a good home-care/self-care planwith an emphasis on prevention. Theconcept of protecting the investmentwas raised. These patients have spentconsiderable financial and time resourceson their oral health. As risk factorsmay increase with age, we shouldprovide them with information andguidance to help them maintain this.Frequently reviewing medical historyand medicine will be important.

PredependencyThese patients present with achronic systemic condition withpotential impact on oral health,which at point of presentation, is wellcontrolled. An example of this typeof patient might be the following:Sarah is 66 years old and is awidow living alone. She is active inher community and attends churchregularly where she has an extensivesocial network. She sometimes uses awalking stick when she feels a little dizzy,and is taking medications for diabetesand high blood pressure but both arewell controlled. She recently had anCONTINUES ON 436A U G U S T 2 015 433

Consider increased use of professional applied products

Oral health care plan Strategy Treatment plan.20

Consider recommending gum chewing and/or salivary

substitutes if indicated.29Production of daily oral care plan.

High Dependency

Inability to receive care elsewhere identied and risk assessment

undertaken and increased frequency of contact unless compellingreasons to maintain current frequency.18Recognition that risk may be greater as result of increasing dependency.Assessment of long-term viability of oral health.Oral health care plan Strategy Treatment plan.Consideration of use of skill mix.21

20

Focusing prevention on easily deliverable products and

therapies, emphasis on pain and infection management.14Further move to professional products, including varnishesand gels.Consideration of prevention of disease complications i.e., chlorhexidine use to prevent respiratory infections.30Production of daily oral care plan.

2014 John Wiley & Sons A/S and The Gerodontology Society. Published by John Wiley & Sons Ltd, Gerodontology 2014; 31 (Suppl. 1): 7787.1 Reproduced with permission.* Consideration of the long-term success, impact and maintenance of current restorative condition, oral health and prevention.** Development or modication of this plan.

Contact is dened as an activity involving contact between patient and the wider dental team.

Based on maintaining function and freedom from infection and pain

Further consideration of strategic importance, repair rather than

Establish link with source of support to ensure that daily oral health plan canbe delivered and that prevention modalities are appropriately implemented.

Minimal intervention to preserve health but consideration of long-term

viability which may lead to more complex treatments being recommended,for example implants to support lower denture.31Use of simple restorative techniques such as atraumatic restorativetechnique.33Change attachment types on implant or tooth supported overdentures.34

Palliative treatment based on patient demand ensuring freedom from pain

or infection, and esthetics where required.14

Ensure that the patient is at the center of discussions to ensure that what is beingdelivered is what is needed.

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CONTINUED FROM 433

anterior tooth extracted following a

persistent periapical infection and thiswas added to her partial denture. Shefinds the additional tooth uncomfortableand wants to know what can be done.Sarah is considered predependantas her diabetes and high blood pressurecould, if they became unstable, adverselyaffect her oral health. She is strugglingwith her adapted denture, which maybe affecting her ability to socialize oreat. The care pathway for predependantindividuals advocates a candid approachto communicating with the patient. It isimportant to articulate the risks of poordisease management with the patient,in this case the polypharmacy, and thisshould impact on the recall intervalfor Sarah. Prevention should be thecenterpiece of a detailed home-care planand consideration should be given to theinclusion of high-fluoride dentifrices, gelsor mouth rinses. In terms of the treatmentoffered to Sarah, this must be consideredin the context of her potentially increasingdependency and therefore should be easyto maintain but may need adaptationover time. Efforts should be made toensure that, within her care record, thecontact details for her family, or perhapssomeone in her church group, are recordedso they may be contacted if Sarah failsto attend her recall appointments.

Medium DependencyThese are patients with an identifiedchronic systemic condition that iscurrently impacting oral health and whoreceive or require support in managingaccess to dental services or maintainingoral health. This category would includepatients who demand to be seen at homeor who cannot get transportation to adental clinic. An example of this typeof patient might be the following:John is living in residential care inthe same town as your dental practice.436A U G U S T

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With assistance, he can attend the

practice, but these appointmentsneed to be scheduled carefully and hiscaregiver must accompany him. Johnhas mild dementia and can consent tohis treatment but has poor short-termmemory and often repeats his questions.He is on a range of medications thathave caused salivary hypofunctionand he complains of a dry mouth.John consumes a large number ofcandies in an attempt to stimulatesaliva and he has an extensivelyrestored dentition in which there is

Prevention should be the

centerpiece of a detailed homecare plan and considerationshould be given to the inclusionof high-uoride dentifrices,gels or mouth rinses.

evidence of new carious lesions and

failing extracoronal restorations. Hedoesnt report any pain at present.John is a patient who is on thetipping point. His medications arehaving a direct impact on his oralhealth and he requires an immediateand aggressive preventive approach.Given his cognitive difficulties,these need to be coordinated withhis caregiver and should includehigh-fluoride products, for example,5000 ppm toothpaste. Plaque controlmeasures should be discussed with himand his caregiver, and his physicianshould be contacted to see if it ispossible to alter his medication regimeto reduce the dry mouth symptoms.Professional prevention, for example,the application of fluoride varnish,

should be commenced with frequent

recalls that should be facilitated betweenthe dental office and the residentialhome. Restorative treatment shouldbe designed with easy maintenance inmind and it may be inappropriate toconsider complex work that may becomeincreasingly difficult to clean in thefuture. Consideration could be given totreatments that might be adapted in thefuture, for example, fixed implant workthat might be changed to removable.14,15Patients in the medium dependencygroup, when questioned in focusgroups, placed access to care as theirtop priority, followed by a pain-free,functional dentition. They fear theirloss of independence will prevent themfrom going to the dentist to receive thecare they need, therefore, assuring themof continued access and facilitating thisare key. The importance of oral hygienemeasures should be made clear to carepersonnel and a written plan is essential.The full care pathway documentprovides further examples of themanagement of patients withincreasing dependency and shouldbe consulted by those practitionerswho serve such populations.1

Cultural/GeneralizabilityCare pathways, such as the SeattlePathway, are designed to be generalizableto a range of populations, health serviceorganizations and cultures. They shouldbe consistent with, or enable theincorporation of, local, regional andnational guidance and regulations. Theyshould be operable in insurance andstate-funded systems. It is therefore arequirement of practitioners to assess theguidance and consider its implementationwithin their practice population.The impact of culture should notbe ignored when considering the needsof patients in this group. Lo described

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the differences between16 cultural

attitudes toward tooth loss, aging anddental treatment. For example, in agiven culture, the ability to eat andsocialize may be more important thanpreservation of individual teeth, whereasfor others the loss of teeth, and anycommensurate perceived esthetic impact,would be considered unwanted.16The conference also considered theskill of the current dental workforce inmanaging the increasing needs of olderdental patients.17 The pathway advocatesthat much can be done for dependentpatients without the need to refer tospecialist services. However, researchsuggests many dentists are concernedwith providing treatment to patientswith complex medical histories or thosewith cognitive impairments. There is,therefore, a need to ensure graduate dentaleducation and continuing professionaleducation courses address these concerns.17

SummaryThe purpose of this article has beento present and describe the rationalebehind the Seattle Care Pathway. Theauthors recognize the pathway may bea first step to providing an evidencebased approach to the managementof this increasingly complex group ofpatients who are destined to become anever-greater proportion of our practicepopulations. The overarching adviceis that prevention, both self care andprofessional, is key for these patientsand the practitioners should be vigilantabout changes in the health and socialcircumstances of their older adult patients.While products and therapies exist forthis cohort of patients, there is a need forrobust clinical trials in this population,as well as further consideration of howdental service funding, either public orprivate, can be leveraged to support theimplementation of effective prevention.

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Root Caries in Older Adults

Dick Gregory, DDS, and Susan Hyde, DDS, MPH, PhD, FACD

A B S T R A C T Older adults are retaining an increasing number of natural teeth, and

nearly half of all individuals aged 75 and older have experienced root caries. Rootcaries is a major cause of tooth loss in older adults, and tooth loss is the most significantnegative impact on oral health-related quality of life for the elderly. The need forimproved preventive efforts and treatment strategies for this population is acute.

Susan Hyde, DDS, MPH,

PhD, FACD, chairs thedivision of oralepidemiology and dentalpublic health at theUniversity of California, SanFrancisco, School ofDentistry. She is the dentaldirector of UCSFsmultidisciplinary fellowshipin geriatrics and facultylead for interprofessionaleducation for the School ofDentistry. Dr. Hyde receivedher dental degree fromUCSF, Master of PublicHealth and doctorate ofphilosophy (epidemiology)from the University ofCalifornia, Berkeley, andcerticates in dental publichealth and geriatrics fromUCSF.Conict of InterestDisclosure: None reported.

Carious lesions are termed either

primary (new lesions on previouslyunrestored surfaces) or secondary (newcaries around existing restorations).They occur on the crowns of teeth andexposed root surfaces. Periodontal diseaseresults in loss of gingival attachment andexposure of the tooths root surface. Rootsurface cementum and dentin are moresusceptible to cavitation because they areless mineralized than enamel and beginto demineralize at a higher salivary pH.Older adults are retaining anincreasing number of natural teeth, andnearly half of all individuals aged 75 andolder have experienced root caries. Rootcaries is a major cause of tooth loss inolder adults, and tooth loss is the mostsignificant negative impact on oral healthrelated quality of life for the elderly.2A false perception exists among dentalprofessionals and policy makers that dentalcaries is, for the most part, only active inyounger people. Several of the clinical,social and behavioral changes common toaging predispose older adults to the highestA U G U S T 2 015 439

Prevalence and Risk Factors

The prevalence of untreated rootcaries is 12 percent for adults aged65-74 and 17 percent for those aged75 and older.5 African Americans andMexican Americans experience moreoral health problems, including dentalcaries, throughout the life course.Lower educational attainment is alsostrongly associated with increasedoral health problems at all agesand across all races (FIGURE 1 ).Aging is often associated with changesin oral morphology, chronic systemicdisease such as diabetes and decreasingdexterity, making personal oral hygienemore difficult, particularly for the oldestand most frail individuals. The painof arthritis and neuropathies make itdifficult to grasp or manipulate a manualtoothbrush. Patients with dementiaexperience a higher prevalence of cariesthan those without dementia, and therates are related to dementia type andseverity. Individuals needing assistancewith oral hygiene and whose caregivershave difficulties providing effective oralcare experience the highest rates.6Another risk factor that oftenaccompanies aging is patients taking440A U G U S T

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multiple medications. More than 500

medications have the potential todecrease salivary flow, which leads toxerostomia and subsequently dentalcaries. Other social and behavioralfactors that contribute to the higherfrequency of root caries in older adultsinclude lack of a perceived need fordental treatment and a history ofsmoking and alcohol consumption.7,8,9Good oral hygiene is also compromisedby existing dental restorations and thepresence of oral prostheses and appliances.Wearing a removable partial denture isassociated with higher rates of dentalcaries. It is unclear whether this is due tothe initial high caries rate which resultedin tooth loss or if the denture has a rolein causing caries due to increased rootsurface exposure on the abutment teeth,food impaction and plaque accumulation.4

There is questionable evidence that

xylitol and sorbitol gum can be usedas an adjunct for caries prevention.15Cariogenic bacteria prefer six-carbonsugars or disaccharides and are not ableto ferment xylitol, depriving them ofan energy source and interfering withgrowth and reproduction. Systematicreviews of clinical trials have notprovided conclusive evidence thatxylitol is superior to other polyols suchas sorbitol 16 or equal to that of topicalfluoride in its anticaries effect.17

Genetic SusceptibilityThere appears to be variation inindividual susceptibility to caries. Intrinsichost factors related to the structureof enamel, immunologic response tocariogenic bacteria and the compositionof saliva play key roles in modulating theinitiation and progression of the disease.Genetic variation of the host factorsmay contribute to an increased risk fordental caries. However, the evidencesupporting an inherited susceptibility

to caries is limited. Utilizing the

SalivaSaliva contains many important cariesprotective components, such as calcium,phosphate and fluoride, which are essentialto tooth surface remineralization. Salivaryproteins and lipids form a protectivepellicle on the tooth surface, while otherproteins bind calcium, maintaining salivaas a supersaturated mineral solution.Bicarbonate, phosphate and peptidesin saliva provide a critical pH-bufferingfunction. With age, the amount of salivaremains stable, however, saliva becomesthicker due to a reduction in serousflow relative to the mucous component,resulting in decreased lubrication orperceived decreased moistness.

FluorideOther than the pre-eruptivemineralization of the developingdentition, systemic benefits of fluorideare minimal. The anticaries effects offluoride are primarily topical in adults.The topical effect is described as aconstant supply of low levels of fluorideat the biofilm/saliva/dental interfacebeing the most beneficial in preventingdental caries. Therapeutic levels offluoride can be achieved from drinkingfluoridated water and the use of fluorideproducts (toothpaste, rinse, gel, varnish).Fluoride can inhibit plaque bacterialgrowth, but more significantly, fluorideinhibits demineralization and enhancesremineralization of the tooth surface.1The most widely used forms of fluoridedelivery have been the subject of severalsystematic reviews, providing strongevidence supporting the use of dentifrices,gels, varnishes and mouth rinses for theA U G U S T 2 015 441

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control of caries progression. Dentifrices

with fluoride concentrations 1,000ppm and higher have been shown to beclinically effective in caries preventionwhen compared to a placebo treatment.More evidence is needed to determinethe benefits of the combined use oftwo modalities of fluoride applicationas compared to a single modality.19Considering the currently availableevidence and risk-benefit aspects,brushing twice daily with a dentifricecontaining fluoride is one of the mosteffective ways to control caries. However,brushing alone does not overcome ahigh bacterial challenge, and additionalfluoride therapy should be targeted towardindividuals at high caries risk. Frequenttopical application of fluoride appears tobe a successful treatment for incipientroot caries lesions by remineralizingdecalcified structure, irrespective ofthe type of fluoride treatment used.1

ChlorhexidineThe use of chlorhexidine for cariesprevention has been a controversial topicamong dental educators and clinicians.Chlorhexidine rinses, gels and varnishes orcombinations of these items with fluoridehave variable effects in caries prevention,and the evidence is regarded as suggestivebut incomplete. The most persistentreductions of mutans streptococci havebeen achieved, in order of more effectiveto less effective, by chlorhexidine varnishfollowed by gels and, lastly, mouth rinses.While chlorhexidine had been widely usedin Europe before gaining FDA approval,the only chlorhexidine-containingproducts currently marketed in theUnited States are 0.12% chlorhexidinemouth rinses. The preferred dosageregimen for rinsing is once a day with 5cc of a 0.12% chlorhexidine gluconatesolution for one week every month fora year.1 Patients should be informed442A U G U S T

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of the likelihood of dark staining of

their teeth during chlorhexidine use,and that the staining is easily removedduring a dental prophylaxis. Bacterialtesting should be used to monitorthe clinical success of chlorhexidinetherapy.20 Better antibacterial therapiesfor high caries risk individuals areneeded, and they must be combinedwith remineralization by fluoride.1Chlorhexidine is effective atreducing the bacterial challenge inhigh caries risk individuals even whencompliance is problematic. In the

new caries than fluoride varnish, and

may be a valuable caries-preventiveintervention. Possible mechanismsfor SDFs clinical success include itsantimicrobial activity against a cariogenicbiofilm of S. mutans or A. naeslundiiformed on dentin surfaces and slowingdown the demineralization of dentin.21While SDF is available from internationalchemists online and has been shown tobe as safe as fluoride varnish, effectivefor treating carious lesions and iswidely used in other countries, it doesnot currently have FDA approval.

Clinical Decision Making

Brushing alone does not

overcome a high bacterialchallenge, and additionaluoride therapy should betargeted toward individualsat high caries risk.

absence of regular professional teeth

cleaning and oral hygiene instruction,chlorhexidine varnish may providea beneficial effect for frail elders andpatients with xerostomia.20 Cervitec Plus(Ivoclar Vivadent Inc., Amherst, N.Y.),a chlorhexidine-thymol varnish, mayhelp to control established root lesionsand reduce the incidence of new rootcaries among institutionalized elderly.It is the only nonfluoride caries agentto receive a favorable recommendationfrom a panel for caries prevention.13

Silver Diamine Fluoride

Recent interest in the antimicrobialuse of silver compounds suggest that silvernitrate (SN) and silver diamine fluoride(SDF) are more effective at arrestingactive carious lesions and preventing

Diagnosis of a carious lesion on a

root surface raises ethical and practicalquestions. Can the lesion be remineralizedwith fluoride therapy or does it requirea restoration? Is it an active or arrestedcarious lesion? Is the root caries causingor likely to cause pain? How do therisks and benefits to the patient of nottreating a carious lesion compare to thoseassociated with restoring it? Does thepatient have access to follow-up care?If the lesion is to be restored, whattechnique and material will result inthe best outcome for the patient? Whatis the patients ability to maintain therestoration and what is the future cariesrisk? Systemic disease burden, xerogenicmedications, diet quality, salivary function,manual dexterity, cognitive ability, theneed for caregiver assistance and accessto care all contribute to caries risk.The literature suggests that there isa fair agreement between visual/tactileappearance of caries and the severity/depth of the lesion. No single clinicalpredictor is able to reliably assess theactivity of a carious lesion.10 However, acombination of predictors increases theaccuracy of lesion activity prediction forboth primary coronal and root lesions.Three surrogate methods have been used

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for evaluating lesion activity (construct

validity); all have disadvantages. Ifconstruct validity is accepted as a goldstandard, it is possible to assess theactivity of primary coronal and rootlesions reliably and accurately at oneexamination by using the combinedinformation obtained from a range ofindicators, such as visual appearance,location of the lesion, tactile sensationduring probing and gingival health.10Treating root caries can be technicallychallenging. The location of the rootcaries may be difficult to access. It oftenmay extend below the gingival margin,making it necessary to retract the gingivawith a clamp, pack retraction cord toexpose the cervical margin of the lesion,or utilize laser or electrosurgery torecontour the gingiva and obtain accessto the lesion. One important and relevantdiagnostic consideration is, What isthe clinicians ability to successfullyrestore a particular carious lesion? Thelocation of the carious lesion on thetooth, the tooths location in the mouthand the patients ability to cooperate allcontribute to the challenge of placing asuccessful restoration. How extensive andclose to the pulp is the carious lesion?How likely is a pulp exposure and thesubsequent need for root canal therapy?Will the operator be able to achieve adry field and have adequate visualizationand access with a handpiece and/orinstruments? Will conservative cariesremoval result in a better outcome forthe patient than aggressive treatment?

Caries RemovalPartial caries removal has beenfound to greatly reduce the risk of pulpexposure.22 For asymptomatic teeth, partialcaries removal generally results in nodetriment to the patient from increasedpulpal symptoms, decay progressionunder restorations or premature loss of

restorations.22 When pulpal exposure is a

concern in treating deep lesions, partialcaries removal is the preferred approach.22In the absence of clinical symptomsof pulpal involvement, stepwise cariesexcavation to stained but firm dentinfollowed by the placement a thin linerof calcium hydroxide or antimicrobialssuch as chlorhexidine-thymol varnishor polycarboxylate cement combinedwith a tannin-fluoride preparation,are all effective in reducing bacteriaand promoting remineralizationof any carious dentin that remainsafter the stepwise excavation.23There is limited scientific evidencefor laser treatment being as effectiveas a rotary bur for removing carioustissue. However, treatment time withlasers is prolonged compared to using atraditional handpiece, and to date noconclusions can be drawn regardingbiological or technical complications orthe cost-effectiveness of the method.24

Restorative Materials: Amalgam,

Composite and Glass IonomerThe longevity (failure rate, mediansurvival time, median age) of silveramalgam fillings has been compared todirect composite fillings in permanentteeth. Amalgam fillings have beenshown to have greater longevity thancomposite fillings. However, compositesand their adhesives are frequentlyreplaced by the next generation ofmaterials with improved properties,making periodic revisions of theseconclusions necessary.25 Economicanalyses report lower costs for amalgamfillings because of the higher complexityof and time needed to place compositefillings. Resin bonding to dentin orenamel requires adequate isolationand saliva contamination control.This is time consuming and oftendifficult to achieve in restoring root

caries lesions at or near the gingival

margin where most occur. Selfetching adhesives provide decreasedclinical application time and reducethe risk of saliva contamination.25A 2009 Statement on DentalAmalgam released by the AmericanDental Association Council onScientific Affairs remains consistentwith a more recent review of theinternational literature on amalgamtoxicity. Various anecdotal complaintsof systemic toxicity because of mercuryrelease from dental amalgam do notjustify the discontinuation of amalgamuse from dental practice or thereplacement of serviceable amalgamfillings with alternative restorativedental materials.26 Available scientificdata show that the mercury releasedfrom dental amalgam restorations doesnot contribute to systemic diseaseor systemic toxicological effects. Nosignificant effects on the immunesystem have been demonstrated withthe amounts of mercury releasedfrom dental amalgam restorations,and only very rarely, have therebeen reported allergic reactions tomercury from amalgam restorations.26No evidence supports a relationshipbetween mercury released from dentalamalgam and neurological diseases.26Glass ionomer, resin-modified glassionomer and composite resin have beencompared in high caries risk patients.Both glass ionomer and resin-modifiedglass ionomer restorations containfluoride and release it into the salivaand adjacent tooth structure. Whileno significant difference in cariesprevention between the two materialshas been observed, reduction in newcaries formation for glass ionomer andresin-modified glass ionomer restorationswas more than 80 percent greaterthan for composite resin restorationsA U G U S T 2 015 443

as demonstrated by radiographic quality

is the single most important predictor forrestoration survival.23,28 When comparedto amalgam, significantly less secondarycaries has been observed at the margins ofsingle-surface glass ionomer restorationsin permanent teeth after six years.29

Atraumatic Restorative Treatment

Atraumatic restorative treatment(ART) is an essential caries managementtechnique for improving access to oralcare. The approach, initiated 25 yearsago in Tanzania, has evolved into a cariesmanagement concept for improvingquality and access to oral care globally.Local anesthesia is seldom needed andonly hand instruments are used to remove

The director of nursing in a local

residential care facility requests aconsultation with a dentist for Mrs.Switzer, who is 86 years old and has afractured maxillary left lateral incisor.Mrs. Switzer was admitted to the facilitythree weeks previously with moderateAlzheimers disease, depression andsevere hypertension. Mrs. Switzerattended her dentist one month beforeentering the facility but did not followthe dentists recommendations forperiodontal debridement, intracoronalrestorations and a fixed partial denture.Before this appointment, Mrs. Switzerhad not been to the dentist in two years,although she claimed to have visited herdentist frequently over the years beforethen. Consequently, she is referred tothe care facilitys dentist for furtherassessment and treatment of the fracturedtooth. The dentist examines Mrs.Switzer to confirm that the maxillaryleft canine has an asymptomatic butcomplete coronal fracture due to rootcaries (F I G U R E S 3AC ). He notes alsothat there is copious plaque and fooddebris throughout the teeth and mouth.

C D A J O U R N A L , V O L 4 3 , N 8

On questioning, Mrs. Switzer reveals

that she drinks tea sweetened withsugar constantly for energy and tobe sociable in the facility, and shetakes multiple medications for bloodpressure, depression and occasionalmemory loss. The dentist requests theradiographs be taken before she entersthe facility to determine the extentof the carious lesions (F I G U R E 4 ).A diagnosis of extensive root cariesinvolving all previously restored teethis made. A treatment plan of extractionof the fractured maxillary left lateralincisor and replacement using anacrylic removable partial denture ismade. The carious lesions are scheduledfor restoration using resin-modifiedglass ionomer material. The patientsdaughter is warned that excavationof the root caries might result intooth fracture. If this occurs, then thefractured teeth would require extraction,denture teeth could be added to theacrylic removable partial denture in themaxilla and/or an additional prosthesiswould be needed for the mandible.Personalized diet and daily mouth carecounseling is provided to the patient,daughter and nursing staff. Daily useof 0.2% neutral sodium fluoride isprescribed for prevention of root caries.

Future DirectionsART is expected to play a significantpart in essential caries management forthe frail elderly, especially as additionalscopes of practice are more widelyincluded in an expanded clinical careteam. One of the indications for theappropriate use of the ART approachis for the elderly who are homeboundor living in institutions. More studiesare needed to investigate the potentialof ART in providing essential cariesmanagement in this population. However,field trials report two-year survival

rates of 90 percent with no significant

difference between ART restorationsusing high-viscosity glass ionomer andthose produced through the traditionalapproach of complete caries removalusing rotary instruments, resulting in ahigher risk of pulp exposure.31 Anecdotalclinical reports of dentists and expandedfunction hygienists and assistantsproviding on-site care for nonambulatoryolder adults provide support from the fieldfor this clinical approach. More researchis needed in a clinical randomizedcontrolled trial environment to providesystematic evidence for this approach. Reprinted from Geriatric Dentistry: Caring for Our AgingPopulation (9781118925454/1118925459) withpermission from John Wiley and Sons.REFERENCES

Dick Gregory, DDS, can be

reached at dgregory@appletreedental.org.A U G U S T 2 015 445

CDA Presentsat your ngertips.Search courses by day, topic orspeaker.Find exhibitors by name andproduct categories and locate themdirectly on the exhibit hall map.Link straight to the C.E. websiteand save a stopp at the C.E.vilion.Pavilion.

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periodonticsC D A J O U R N A L , V O L 4 3 , N 8

Aging Periodontium, Aging

health in the elderly patient. While age-related alterations in periodontal tissues andthe immune system may make an elderly patient more susceptible to periodontalbreakdown, age itself is not a major risk factor for periodontal diseases. Rather,individual age-associated factors such as systemic diseases, medications and changesin behavior, motor function and cognitive function should be considered for eachelderly patient when making treatment decisions.

AUTHORMark Ryder, DMD, isthe chair of the division ofperiodontology and directorof the postgraduate programin periodontology at theUniversity of California,San Francisco, School ofDentistry.Conict of InterestDisclosure: None reported.

n the U.S. and most of the developed

and developing world, there is anincreased proportion of the populationthat is considered elderly. Numerousfactors, including declining birth ratesand longer life spans because of improvedtreatment and prevention measures, haveplayed a major role in this demographicshift.1 Along with this demographicshift there has been a physiological,psychological and philosophical shiftamong practitioners and the public withthe perception of what is considered oldage. Such changes are apparent in theemergence of concepts of healthy aging2and the goal of adding life to years ratherthan years to life.3 Part of these newattitudes in improving the quality of the

life for the elderly is the maintenance of a

healthy and functional natural dentition.Maintenance of a healthy dentitionrequires an understanding of the causes,diagnosis, risk assessment and timelytreatment of the two primary causes oftooth loss, periodontal disease and caries.This paper presents the current state ofknowledge and opinion on approachesto periodontal diseases and periodontaltreatment in the elderly with an emphasison consensus, conclusions and futuredirections for dental practitioners.The central question in addressingthe role of aging in periodontal diseaseis whether aging itself is a risk factor forthe incidence, severity and progressionof periodontal disease. In other words,A U G U S T 2 015 447

periodonticsC D A J O U R N A L , V O L 4 3 , N 8

is periodontal disease a risk factor for

periodontal disease initiation and/ordisease progression? By risk factor we meana condition or factor that is associatedwith the disease after adjusting for othercontributing factors, such as tobacco use,plaque levels and systemic conditions, andhas been demonstrated in longitudinalstudies. While it has been demonstratedfrom large epidemiological surveys thatthe elderly have a higher prevalenceand severity of periodontal diseases,4-6particularly among African-Americansand Hispanics,7 as measured by level ofloss of periodontal support when comparedto a younger cohort, these observationsneed to be interpreted with caution.Firstly, employing levels of loss of supportof alveolar bone, clinical attachmentloss, recession, etc. for determining theincidence and/or severity of periodontaldisease at a single observational timepoint does not indicate the presence ofactive periodontal breakdown, or therate of periodontal breakdown itself.Determination of active disease orrate of breakdown would be the mostaccurate measures of the presence ofperiodontal disease itself. Rather, thesemeasures from surveys of larger generalpopulations at a single time point reflectthe long-term cumulative effects of pastperiodontal inflammation from bacterialplaque, as well as the cumulative effectsof physiological and nonphysiologicalocclusal forces, psychological stress, oralhabits and hygiene techniques, tobaccouse, medications, compensation forocclusal wear, continued tooth eruptionand gingival recession.8-10 Secondly,the attitudes toward the importance oforal hygiene and importance of bothmaintenance by the patient and regularmaintenance by the dental practitionerhave improved over successive generationsof patients.11 Therefore evidence ofloss of periodontal support among448A U G U S T

2 015

the elderly may reflect in large part

these differences in attitudes in theiryounger years with an accumulatedeffect toward their current condition.Thus, the prevailing opinion amongthe periodontal research community isthat age alone is not a major risk factorfor the incidence of new destructiveperiodontal disease or in its rate ofprogression. In a periodontally healthyelderly patient some gingival recessionand slight horizontal bone loss may beobserved as part of the normal agingprocess. However, the susceptibility

Age alone is not a major

risk factor for the incidenceof new destructiveperiodontal disease orin its rate of progression.

of an individual elderly patient to

periodontal breakdown from inflammatoryperiodontal diseases is more dependenton that individual patients biological,behavioral, medical and pharmacologicalconsiderations that accompany aging.Specifically, the dental practitioner shouldconsider four broad areas when assessingperiodontal risks in the elderly patient: The effects of aging on theintegrity and function of theperiodontal tissues themselves. The effects of aging on the local andsystemic response to periodontalplaque biofilm and how this maymanifest in clinical signs of disease. The effects of systemic conditionsand medication associated withaging on the incidence, severity andprogression of periodontal diseases.

The effects of aging on motor

function, cognitive function andbehavioral changes that couldaffect the ability to removebacterial plaque deposits.Aging and the periodontal tissues. It iswell-known that with aging, the abilityof tissues in the body to regenerate andrepair diminishes over time.12,13 This isdue in part to the reduced ability of cellsto divide, leading to a reduction in thenumber of cells in the full range of tissuesin the body. These changes have beenobserved in periodontal tissues includingthe gingival epithelium, connectivetissues and bone that form theperiodontal complex.12,13 In particular,the reduction of numbers of fibroblaststo maintain and repair both gingivalconnective tissues and periodontalligament may lead to an increase rigidityand/or loss of elasticity in these tissues.This loss of elasticity could lead toa reduced ability of the periodontaltissues in general and the periodontalligament complex in particular to absorbboth natural and nonphysiologicalocclusal forces. In addition, the naturallonger-term exposure of collagen inperiodontal connective tissues to freeradicals could lead to damage, reducedfunction and/or death of epithelialcells and to fibroblasts, osteoblastsand cementoblasts of the periodontaltissues,13,14 as well as cross linking ofcollagen fibers with reduced elasticityin the periodontal ligament support.These normal aging changes maycontribute to a small and gradualreduction in the periodontal supportin the elderly, even in the absence ofa history of periodontal inflammationdue to plaque inflammation.Aging and host response in periodontaldiseases. As with other tissues of thebody, periodontal tissues require a fullyfunctional host defense in general,

C D A J O U R N A L , V O L 4 3 , N 8

and immune response in particular, to

defend against microbial pathogens.A reduction in these host defenses,or immunosenescence,15 has receivedconsiderable attention over the pastseveral decades. The rapid first lineof defense against bacterial plaqueknown as the innate immunity system,which includes the epithelial barrierand normal function of neutrophils tomigrate, engulf and break down bacteria,as well as the adaptive immune system,which includes a variety of T and Blymphocyte responses with production ofantibodies, cytokines and chemokines,are reduced in the aging process itself.15,16However, it remains unresolved asto whether diminished function inthese two immune systems and otherprotective host responses in a medicallyhealthy elderly patient leads to moresevere forms of periodontal disease. Inaddition, there are conflicting reportsas to whether older patients have analtered gingival inflammatory responsein experimental gingivitis studies whencompared to a younger population.13,17Systemic diseases, conditions andmedications in the elderly and implicationsfor periodontal diseases. When consideringthat the prevalence of chronicconditions and diseases in the elderly arehigher and that most of these conditionsand diseases require treatment bymedication,3,18 it is understandable thatmany of these conditions are associatedwith a higher prevalence and severity ofperiodontal diseases in this population.While a complete discussion of theseassociations would be beyond thescope of this review, several examplescan be discussed to demonstrate thefull range of these associations.For example, with increasing age, theprevalence of type II diabetes increases.It is now well-established that less thanoptimal glycemic control with these

patients is associated with a higher

incidence and prevalence of periodontaldisease.19 Hormonal changes in elderly,postmenopausal women increase theincidence of osteoporosis, which hasalso been observed in the alveolarsupporting bone.20 It is associated withan increased loss of alveolar bonesupport while other studies found nosuch association in this population.Medications taken for a variety ofchronic conditions and diseases areassociated with reduced salivary flow18and increased susceptibility to plaque

The chronological age of

the elderly patient may notreect the actual overallphysical health, cognitivefunction and motor functionsof that particular patient.

accumulation. Older patients may

also exhibit the accumulative effectsof stress, which are associated with anincreased loss of alveolar bone supportand reduced immune function.21 Inaddition, the increased prevalenceof depression in the elderly3 may beassociated with both reduced immunefunction and poorer plaque control.Motor function, dementia andperiodontal disease. With the increaseof the proportion of very elderly in thegeneral population, the prevalence ofimpaired mental and motor functionscan lead to both impaired physical andmental abilities to practice effectiveplaque control measures. In additionto these objective declines in motorand cognitive abilities in some elderly,the more subjective self-efficacy of

the individual aging patient should

be taken into consideration.11 Selfefficacy is defined as the self-perceptionof the individual patient to controland modify his or her respectivebehaviors to treat and prevent his orher respective conditions and diseases.For periodontal diseases, these includefollowing plaque control regimens,seeking dental care on a regular basisand following through on proposedtreatments from the dental practitioner.Several considerations shouldbe kept in mind when consideringchanges in prevention and therapy ofperiodontal diseases for the elderly.Perhaps the most important of theseis that the chronological age of theelderly patient may not reflect theactual overall physical health, cognitivefunction and motor functions of thatparticular patient. Some clinical thoughtleaders have proposed a multipletiered system of the elderly patient,such as young-old aged, middle-oldaged and old-old aged patient, basedon specific age brackets and/or specificquality of life and quality of functionmeasures. It is important to keep inmind from the previous discussion ofother factors associated with aging,particularly medical and pharmacologicalconsiderations, that these should beaddressed in any periodontal treatmentplan for the elderly patient.Among these considerations aremaintaining adequate dietary andnutrient intake to prevent prematureloss of alveolar bone density and supportthrough recommended dietary intakeof calcium or calcium supplementsand vitamin D.22 In addition, forpostmenopausal women, there issufficient evidence that an estrogensupplement has beneficial preventiveeffects for alveolar bone loss.20 However,because of the risk of reported adverseA U G U S T 2 015 449

periodonticsC D A J O U R N A L , V O L 4 3 , N 8

side effects and events for estrogen,

estrogen supplementation should bedetermined for such patients at risk bytheir physicians. In addition, chronicmedical conditions that increasein prevalence with aging and areassociated with increased periodontaldisease and loss of support should alsobe controlled in collaboration withthe elderly patients physician. Whenconsidering the strong association ofpoor glycemic control with type IIdiabetes with periodontal disease,21appropriate measures should be taken toassure this condition is under control.As the prevalence of one or morechronic conditions requiring medicationbecomes increasingly common in thispopulation, the dental practitionershould be aware of potential adverseeffects some of these medications haveon the oral cavity in general and theperiodontal tissues in particular.18,23 Theseinclude the range of medications thatresult in a reduced salivary flow, whichwould make the patient more susceptibleto both periodontal diseases, andcoupled with the increased prevalenceof gingival recession, root caries. Highfluoride rinses, dentifrices and topicalapplication of fluorides may havebeneficial preventive effects for both rootcaries and periodontal diseases. If thepatient is taking a medication such assome classes of calcium channel blockersthat are associated with the gingivalenlargement, the dentist should alsoconsult with the physician to explorealternative medications with the samesystemic beneficial effect but with lessadverse effects on the periodontal tissues.A second major consideration fortreatment decisions for the elderlypatient is the actual treatment approachitself. Several practitioners have proposedthe concept that the principal goal ofperiodontal therapy in the elderly patient450A U G U S T

2 015

should focus on maintaining a functional

dentition as opposed to restoring allteeth to full periodontal health.23,24 Thistreatment philosophy implies that givena young and an old periodontal patientwith the same clinical levels of lossof periodontal support, the treatmentapproach of frequent debridement andfrequent maintenance would be thepreferred approach for the elderly patientas opposed to debridement followedby some form of periodontal surgeryfor the younger patient. However, thisphilosophy should be tempered by the

The dental practitioner

should be aware of potentialadverse eects some of thesemedications have on the oralcavity in general and theperiodontal tissues in particular.

fact that a healthy elderly patient may

have several more decades of a highquality of life. Furthermore, consensusopinion from studies comparing thehealing response to periodontal surgicalprocedures between older and youngerpatients is that the healing responses arecomparable.24 Therefore age itself shouldnot be a contraindication for performingsurgery, placement of implants, etc.Nevertheless, medications, oralhabits, systemic factors associated withthe incidence and severity of periodontaldisease in general, and the ability of thepatient to perform regular and effectivemechanical plaque control regimensstill need to be taken into considerationfor treatment decisions. These includethe elderly patients motor ability tomaintain such a plaque control regimen.

It is widely accepted that the success

of any form of nonsurgical and surgicaltreatment is primarily dependent on apatients plaque control regimen. Use ofantimicrobial rinses with demonstratedantiplaque and antigingivitis activitycan be valuable adjuncts for elderlypatients, particularly those with reducedmotor and/or cognitive function.Another major consideration for thedecision to perform periodontal surgeryon an elderly patient is whether thatpatient is currently taking or has takensome form of bisphosphonates to protectagainst fractures associated with loss ofbone mineral density. Such patients maybe at risk for postoperative osteonecrosisof the jaw. As most periodontalsurgical procedures are elective, specialconsiderations and precautions shouldbe taken in consultation with thepatients physicians for those patients onintravenous bisphosphonates or for thosepatients who are currently taking or havetaken bisphosphonates intravenously,have taken oral bisphosphonates over athree year period or longer, have a historyof diabetes or an immunosuppressivecondition or who are taking orhave taken corticosteroids or otherimmunosuppressive medications.20In conclusion, the diagnosis,treatment planning and treatmentdecision for the elderly patient shouldtake into consideration the knownrisk factors for periodontal disease thatare prevalent with higher frequencyin the elderly patient. At present, theprevailing view is that age itself in amedically healthy and functional elderlypatient may be of minimal significancein the treatment of periodontal diseases.While the American Academy ofPeriodontology (AAP) has publishedstatements and/or position papers onperiodontal considerations in the childand adolescent population, no similar

C D A J O U R N A L , V O L 4 3 , N 8

resources are currently available from

the AAP for periodontal treatmentconsiderations for the elderly.Nevertheless, for the individual elderlypatient, the dental practitioner shouldunderstand and assess the role of otherage-related conditions such as systemicdiseases, concomitant medicationsand reduced motor and/or cognitivefunction as well as the overall goals ortherapy for that individual patient. Suchan understanding of these treatmentconsiderations for the elderly patient willhelp that patient maintain a functioningdentition for a higher quality of life.

CONE BEAM COMPUTERIZED TOMOGRAPHY 2015:

SEPTEMBER 9-13, 2015

Napa Valley, CAPresented at the

Course catalog on our website

http://unlvdentalce.comOr Contact: Roxane SantiagoPh: 702-774-2822

Were on

unlvdentalceA U G U S T 2 015 451

Be a partof the story.Its a tale of healing, resiliency,strength and empowerment. Throughthe CDA Foundation, thousands ofCalifornians who need it most gainaccess to dental care. Participatein Foundation events and put yourcompassion into action.Help create the condence, dignityand joy that come with healthy smilesand lead to brighter opportunities.Join us at cdafoundation.org/events.

Michael J. Helgeson,DDS, is the CEO andco-founder of Apple TreeDental. He completedhis dental degree and atwo-year postgraduatefellowship in geriatricdentistry at the Universityof Minnesota.Conict of InterestDisclosure: None reported.

he July and August issues of the

Journal highlight the multiplechallenges we face as a societyand as dental professionals tocare for our aging patients,parents and grandparents. Weundoubtedly possess sufficient expertiseto successfully prevent and treat dentaldiseases. And yet, older adults and othervulnerable people continue to sufferdisproportionately from dental diseases.Apple Tree Dentals (Apple Tree)Community Collaborative Practicemodel illustrates a sustainable, patientcentered approach to overcomingbarriers to care across the lifespan.

Why Apple Tree Dental?

Multiple national organizationsand initiatives have highlighted oralhealth as essential to overall healthand called for the developmentof safe, effective, accessible andaffordable systems of care (TABLE ).

As baby boomers reach the age of 65,

there are many more elders who havekept more of their natural teeth and havemuch higher expectations regarding dentalcare in their old age than did previousgenerations.2 Older adults, particularlythose who live in long-term care settings,suffer disproportionately from active anduntreated mouth infections, aging andill-fitting dentures, and impairments insalivation and masticatory functions. Manyare more dependent upon others for helpwith daily mouth care than children are.They are also more likely to have chronicconditions, such as diabetes and heartdisease, which are negatively affected bymouth diseases. Aspiration pneumonia,a leading cause of hospitalization anddeath in elders, has been directly linkedwith bacteria from the mouth.3 Formultiple reasons, institutionalized andcommunity dwelling elders are oftenunable to access traditional dental officesand clinics to the same degree as youngerand much healthier population groups.4Such access disparities, in combinationwith the significant health and financialconsequences of untreated mouth diseasesin vulnerable adults, have come to theattention of policymakers and funders andresulted in calls for sustainable oral health454A U G U S T

FIGURE 4 . Dr. Michael Helgeson, Apple Trees

CEO, with a Mobile Dental Oce used to providecomprehensive dental care in a variety of settings.

FIGURE 5 . Specially equipped trucks are used to

Administration for Community

Living (formerly the U.S.Administration on Aging)Oral Health for Older AdultsSubject Matter Expert Group developing best practice models. Special Care Dentistry Association advocating for dental care forpeople with disabilities, olderadults and people requiringhospital-based dental care.Apple Tree has been recognized asa leading model by the American andCalifornia Dental Associations, in theSurgeon Generals Call to Action and bynational foundations including the RobertWood Johnson and Kellogg Foundations.7

From its inception in 1985, Apple

Tree has been recording diagnosticcodes along with billing informationin its custom information systems. Theresult is an unprecedented longitudinaldatabase, which has been used byresearchers to understand the impact ofprevention and treatment on oral healthoutcomes for institutionalized elders.8

transport multiple Mobile Dental Oces to community

How Does Apple Tree Deliver Care?

Although often referred to as asafety net provider, Apple Tree isnot content to catch people who havealready fallen into a dental access chasm.Instead, Apple Tree utilizes a proactive,prevention-oriented, patient-centeredpractice approach, called communitycollaborative practice, to deliver dentalcare and education. Apple Trees deliverysystem goal is to reach at-risk individualswhen they are healthy and to provideeducation, prevention and restorativecare to keep them healthy. Apple Treesphilosophy is to practice dentistry as anintegrated team of professionals focusedon meeting the needs of children,adults and elders across the lifespan.Apple Tree employs unique workforceteams that include dentists, oral surgeons,nurse anesthetists, advanced dentaltherapists, dental hygienists, dentalassistants, community care coordinatorsand lab technicians. Throughcollaborative practice, dental hygienistsare able to serve as front line clinicians incommunity settings as described below.

C D A J O U R N A L , V O L 4 3 , N 8

FIGURE 6A .

FIGURE 6B .

FIGURE 6C .

FIGURES 6A6C . Apple Trees Centers for Dental Health are equipped to serve people with special needs. Shown here is a ceiling lift used to transfer nonambulatory

patients into a dental chair.

Delivering On-Site Care

Apple Trees on-site services canbe delivered at a wide variety ofcommunity sites within a 60-minutetravel time radius of each Center forDental Health (F I G U R E S 4 and 5 ).Community partnerships allow AppleTree to co-locate on-site dental serviceswithin long-term care facilities and othersettings where people live, learn andreceive other health and social services.Sometimes described as a hub and spokedelivery system, the model creates anaccessible care network linked via a fullycertified electronic health record (EHR)and allows multiple points of accessiblecare for patients and communities.Apple Tree uses both lightweightportable equipment and heavier custommobile units to provide on-site care inshared spaces within long-term carefacilities and other community settings.Portable dental units are transportedin a car or minivan and used by dentalhygienists to provide preventive services.For restorative and surgical services,specially designed trucks can transportmultiple complete Mobile DentalOffices. In a carefully planned route,staff truck drivers pick up and drop offone or more complete Mobile DentalOffices at each scheduled location inthe afternoon and evening, outside ofnormal business hours. On-site dentalcare teams provide dental care at eachlocation for one or more days accordingto the number of patients due to be seen.

The Apple Tree Mobile Dental Office

is nearly identical ergonomically andfunctionally to the equipment in AppleTrees Centers. One difference is thatthe dental chair and other units are onwheels so they can be spread out, makingit easier to safely transfer patients toand from wheelchairs. Dental treatmentmay also be provided at a Center, whereoperatories are designed to accommodatewheelchairs, have specialized lifts totransfer patients into the dental chairand are equipped for sedation if requiredfor a successful visit (F I G U R E S 6 A 6 C ).Long-term care residents in facilitiesserved by Apple Tree enter thedental care system through a programestablished for all residents and managedby a dental director. Similar to a nursingfacilitys medical director, Apple Treetakes on the role of dental director,working closely with nursing facility staffto establish programs and processes thathelp ensure that every residents oralhealth needs are met. The MinimumData Set (MDS) is a standardized healthassessment instrument used to assess theoverall health of older adults admittedto nursing facilities. Research hasdocumented that oral health conditionsare typically underreported when theMDS is completed by nurses or aides,that the majority of dependent residentsare resistant to daily oral care and alsosuggests that most receive inadequateoral health care.9 To provide accurateoral health assessments, Apple Trees

on-site dental hygienist becomes part

of the nursing facilitys assessment teamand is responsible for completing the oralhealth portions of the MDS. In addition,the hygienist develops a personalizeddaily mouth care plan for each newresident, coaches facility caregivers onhow to care for residents teeth anddentures, triages residents needingfollow-up care and provides periodic inservice education for the facilitys staff.For nursing facility residents choosingApple Tree as their dental provider,community care coordinators on staffat Apple Tree take all necessary stepsto obtain consent for treatment fromthe responsible party, facilitate anddocument needed medical-dentalconsultations and schedule on-sitedental appointments for treatment.On-site dental treatment is scheduledon a regular basis throughout the yearby a consistent team ensuring timelycare and strong patient-providerrelationships. When residents haveextensive disease or special needs,they may also be scheduled at a nearbyApple Tree center, where care can beseamlessly provided using the same EHR.

A Sustainable SolutionHigh levels of uncompensated careassociated with Medicaid and uninsuredpopulations make it difficult or impossiblefor most private practices to acceptsignificant numbers of public programand low-income patients. In order toA U G U S T 2 015 457

provide evidence-based care.

Include collaborative andmultidisciplinary teams workingacross the health care system. Foster continuous improvementand innovation.All these markers of success areevident in Apple Trees foundingmission and the evolution of its model.With a culture of patient-centeredinnovation, Apple Tree has continuallyincorporated new providers, newtechnologies and evidence-basedservices into its practice. The provisionof on-site care by interdisciplinaryteams eliminates transportationbarriers and helps integrate oral healthwith other health care services.

Program$13,218,82792.7%

FIGURE 8 . 2014 expenses by category.

Management and fundraising make up a small portionof Apple Trees expenses.

CONTACT US FOR A FREE CONSULTATION

WWW.CALPRACTICESALES.COM

Phone: (714) 639-2775

CA DRE #00491323

RM Matters

C D A J O U R N A L , V O L 4 3 , N 8

Accounting Controls Can Prevent Dishonest Behavior

TDIC Risk Management Sta

mbezzlement is typicallydefined as the theft of moneyor property by a person trustedwith those assets. It usuallyoccurs in employment settings,and small businesses suffer more lossesfrom fraud than larger organizations,according to the Association ofCertified Fraud Examiners.Analysts with The DentistsInsurance Company say dentists mayinadvertently put their practices at riskfor fraud by trusting a single employeewith sole financial responsibility orby not reviewing accounts payableand receivable. However, thisvulnerability can be reduced throughawareness of red flag behaviors anda few key accounting protections.Fraudulent activity can happenin a number of ways, and TDIC casestudies show instances of employeesdeleting appointment and ledger entries,endorsing patient checks to personalaccounts, forging payroll checks,modifying payroll, misappropriatinga credit card and using a signaturestamp without authorization.Jennifer Duggan, a NorthernCalifornia attorney specializing inbusiness and employment law, saysthere are also more sophisticatedschemes in which employees fabricatefictitious vendors, create nonexistentemployees, receive kickbacks frompatients or from vendors for awardingcompany contracts or actually coercesubordinate employees to carry out theft.Sometimes employees forgesignatures on checks and sometimesthe employees are authorizedsignatories, said Duggan.Duggan notes that the thief is moreoften than not a highly trusted employee.

The employee is viewed

within the practice asa loyal, trusted, givingindividual and would belast on a list of peopleyou might suspect.

The prototypical thief is a longtime employee who is extremely

familiar with the financial aspectsof your business. He or she interactswith clients and vendors, and mayhandle or process accounts receivable,accounts payable or bankingfunctions for the practice, she said.The employee is viewed within thepractice as a loyal, trusted, givingindividual and would be last on alist of people you might suspect.

You are not a policy number.

And at The Dentists Insurance Company, we wont treat you likeone because we are not like other insurance companies. We werestarted by, and only protect, dentists. A singular focus that leadsto an unparalleled knowledge of your profession and how to bestprotect you. It also means that TDIC is in your corner, because withus, youre never a policy number. You are a dentist.

Contact the Risk Management Advice Line at 800.733.0634.

Protecting dentists.Its all we do.thedentists.com

A U G U S T 2 015 461

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This creates a delicate situation

for practice owners, but experts saybasic awareness of red-flag behaviorkeeps employers from having to beunnecessarily suspicious. Red flagsinclude an ever-present employeewho comes in early or stays to closeup after everyone else has gone homeor someone who regularly refuses totake a vacation. Illicit activity maysurface if the employee is required tobe away from work for a week or twoand is not able to cover up the trailof fraud. Other things to be aware ofare financially frustrated employeeswho are always short on cash orterritorial employees who refuse to

cross-train coworkers. Analysts say

one red flag is not typically causefor alarm, but a combination ofthese behaviors warrants concern.TDIC analysts say practiceowners lose more than money whenfraud shatters the family feelingand trust in the office. When anemployee steals from the practiceowner, the owner feels betrayed andcan have a hard time recoveringfrom that, notes a senior analyst.By implementing accountingcontrols, small business ownerscan significantly reduce thechances of becoming a victim ofemployee theft, Duggan says.

Can I get all cash for the sale of my practice?

If I decide to assist the Buyer with financing, how can I beguaranteed payment of the balance of the sales price?Can I sell my practice and continue to work on a part time basis?How can I most successfully transfer my patients tothe new dentist?What if I have some reservation about a prospectiveBuyer of my practice?How can I be certain my Broker will demonstrateabsolute discretion in handling the transaction in allaspects, including dealing with personnel and patients?What are the tax and legal ramifications when adental practice is sold?

QUESTIONS MOST OFTEN ASKED BY BUYERS:

1.

Can I afford to buy a dental practice?

2.

Can I afford not to buy a dental practice?

3.

What are ALL of the benefits of owning a practice?

4.5.

LEE SKARIN& ASSOCIATES INC.

QUESTIONS MOST OFTEN ASKED BY SELLERS:

What kinds of assets will help me qualify

for financing the purchase of a practice?Is it possible to purchase a practicewithout a personal cash investment?

6.

What kinds of things should a Buyer consider when evaluating a practice?

7.

What are the tax consequences for the Buyer when purchasing a practice?

Lee Skarin & Associates have been successfully assisting Sellers and Buyersof Dental Practices for nearly 30 years in providing the answers to these and otherquestions that have been of concern to Dentists.Call at anytime for a no obligation response to any or all of your questionsVisit our website for current listings: www.LeeSkarinandAssociates.com

2IFHV

805.777.7707818.991.6552800.752.7461CA DRE #00863149

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CONTINUED FROM 462

Running an accounts payable

history to review invoicenumbers and amounts.Providing specific instructionsor guidelines to your bankincluding a list of your approvedvendors and authorized signers.Watching for an increase inpatient refunds, adjustments orbad-debt write-offs. An unusualnumber of accounts turned over toa collection agency and a declinein the gross income or profitabilityof the practice is suspicious.Discrepancies between accountsreceivable records and patient

statements should also be suspect.

Noticing any increase in patientcomplaints regarding theiraccounts, which could indicatefraudulent activity or a needto develop a policy clarifyingaccount procedures with patientsand staff. Reviewing andresponding to patients concernspersonally is recommended.If you discover facts indicatingthat you are the victim of employeefraud, call TDIC immediately. Trainedanalysts will discuss the situation withyou, including documentation of thefraud. Practice owners with evidence

of fraud should also be prepared to call

the police. TDIC offers identity theftrecovery for the individual dentistunder its Professional Liability policy.The business owners property policycovers employee dishonesty. In orderfor coverage to be effective, practiceowners must file a police report andsubmit it to the claims department. Contact TDICs Risk ManagementAdvice Line at 800.733.0634.

SOUTHERN CALIFORNIA OFFICE

Marketing and Advertising Rules

CDA Practice SupportMarketing and advertising are key tothe success of any dental practice. Dentistsand their marketing consultants need tobe aware of marketing and advertisingrules to ensure their ventures arecompliant. The state Dental Practice Act(DPA), Health Insurance Portability andAccountability Act (HIPAA) and stateprivacy laws apply, and dentists also shouldkeep the CDA Code of Ethics in mind.

practice, or any printing or writing on

novelty objects or dental care products.Advertising does NOT include (1) anyprinting or writing used on buildings oruniforms where the purpose of the writingis for identification or (2) any printingor writing on memoranda or othercommunications used in the ordinarycourse of business other than solicitationor promotion of the dentists practice.

How does the state Dental Practice Act

(DPA) affect marketing and advertising?In general, the DPA: Defines advertisingor advertisement andstates what dental practiceadvertising may include. Prohibits the use of false,misleading or deceptivestatements, images or claims. Prohibits the advertisement of aguarantee of any dental service. Prohibits compensation(including thank-you gifts) andinducements for patient referrals. Requires a permit if the dentalpractice uses a name otherthan the name under which adentist is licensed to practice(fictitious name permit). Establishes rules for groupadvertising and referral services. Establishes rules for advertisingfees, discounts and dentures.

What are the rules for advertising fees

and discounts?Any fee advertisement shall be exact,without the use of phrases, including,but not limited to, as low as, and up,

What is considered advertising?

The DPA defines advertisingor advertisement as any written orprinted communication for the purposeof soliciting, describing or promotinga dentists licensed activities, or anydirectory listing caused or permittedby a dentist that indicates his or herlicensed activity, or any radio, television,or airwave or electronic transmissionthat solicits or promotes the dentists

lowest prices or words or phrases of

similar import. Any advertisement thatrefers to services, or costs for services,and that uses words of comparison shallbe based on verifiable data substantiatingthe comparison. Any advertising shallbe prepared to provide informationsufficient to establish the accuracy of thatcomparison. Fee advertising shall notbe fraudulent, deceitful or misleading,including statements or advertisementsof bait, discount, premiums, gifts orany statements of a similar nature. Inconnection with fee advertising, thefee for each product or service shall beclearly identifiable. The fee advertised

When Looking To Invest In Professional

Dental Space Dental Professionals Choose

Linda Brown30 Years of Experience Servingthe Dental Community ProvenRecord of Performance

P.O. Box #6681, WOODLAND HILLS, CA. 91365

CA Representative for the National Association of Practice Brokers (NAPB)

468A U G U S T

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for products shall include charges

for any related professional services,including dispensing and fitting services,unless the advertisement specificallyand clearly indicates otherwise. Feeadvertising for a dental service mustfully disclose all services customarilyincluded by the dental profession aspart of the advertised service, includingbut not limited to necessary diagnoses,radiographs, restorative treatment, drugs,local anesthesia or analgesia, materials,laboratory fees and postoperativecare. The advertisement must alsodisclose any additional services, notpart of the procedure but for whichthe patient will be charged, togetherwith the fees for such services.The advertisement ofa discount must: List the dollar amount of thenondiscounted fee for the service. List either the dollar amount of thediscount fee or the percentage ofthe discount for the specific service. Inform the public of the length oftime the discount will be honored. List verifiable fees. Identify specific groups that qualifyfor the discount or any otherterms, conditions or restrictionsfor qualifying for the discount.What about programs that rewardpatients or others for referrals of newpatients to the practice?This question comes up a lot inCDA Practice Support. Dentistsand other health care providers arerequired to comply with Business andProfessions Code Section 650(a),which states, Except as providedin Chapter 2.3 (commencing withSection 1400) of Division 2 of theHealth and Safety Code, the offer,delivery, receipt, or acceptance by anyCONTINUES ON 470

CARROLL& C O M P A N Y

Matching the Right Dentist

to the Right Practice

Complete Evaluation of Dental Practices & All Aspects of Buying and Selling Transactions

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person licensed under this division or

the Chiropractic Initiative Act of anyrebate, refund, commission, preference,patronage dividend, discount, orother consideration, whether inthe form of money or otherwise, ascompensation or inducement forreferring patients, clients, or customersto any person, irrespective of anymembership, proprietary interest, orco-ownership in or with any personto whom these patients, clients, orcustomers are referred is unlawful.What are the limitations establishedby HIPAA and state privacy laws?State and federal laws overlap inthe regulation of a dental practices useof patient information for marketingpurposes. The federal HIPAA PrivacyRule and the state Confidentiality ofMedical Information Act (CMIA)require a dental practice to obtaina patients authorization prior tousing patient health information tocommunicate about a product or servicethat encourages a recipient of thecommunication to purchase or use theproduct or service, or to give to anotherentity to market its product or service.Patient authorization is not required forthe following types of communicationsfor which the practice is not financiallyremunerated by a third party: Making a patient aware of ahealth-related product or service(or payment for such product orservice) that is included in thepatients dental benefit plan. Providing patient treatment. Coordinating care with otherproviders, such as nursing homes. Providing inexpensive itemswith the practice name andcontact information. Face-to-face communication.If a dental practice receives financialremuneration, including, but not limited470A U G U S T

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to, gifts, fees, payments, subsidies

or other economic benefits, from athird party for making any marketing,treatment or health care operationscommunication, the practice mustobtain authorization from the patientprior to making that communication.Additionally, state law requiresthe dental practice to: Notify the individual receivingthe marketing communication intypeface no smaller than 14-pointtype of the fact that the practicehas been remunerated and thesource of the remuneration. Provide the individual withan opportunity to opt out ofreceiving future remuneratedcommunications. The communication must containinstructions in typeface no smallerthan 14-point type describinghow the individual can opt out ofreceiving further communicationsby calling a toll-free number ofthe dental practice making theremunerated communications.No further communication maybe made to an individual whohas opted out after 30 calendardays from the date the individualmakes the opt-out request.How does the CDA Code of Ethicsgovern dental marketing and advertising?Section 6 of the CDA Code ofEthics advises that dentists have theobligation to represent themselves in amanner that contributes to the esteemof the profession. The standard forjudging the ethical propriety of anydentists advertisement to the publicis whether the ad, taken as a whole,is false or misleading in any materialrespect. A dentist should always ask,Could my ad be misinterpreted orpotentially misleading to someone whoknows nothing about my practice or

my profession? The rationale for the

standard is protection of the public;a dentists advertising should containany information that a patient wouldconsider necessary to make informedchoices about practitioners andservices. The CDA Code of Ethics,Advisory Opinion 1.G.1, also advisesdentists that, in many circumstances,promotional activities on schoolgrounds are considered unethical.Information on additional marketingand advertising rules can be found inthe article, Dental Practice Marketingand Advertising 101. The article andsample patient authorization forms areavailable at cda.org/practicesupport. Regulatory Compliance appears monthlyand features resources about laws andregulations that impact dental practices. Visitcda.org/practicesupport for more than 600practice support resources, including practicemanagement, employment practices, dentalbenefit plans and regulatory compliance

Periscope

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Periscope oers synopses of current ndings in

dental research, technology and related elds

PEDIATRICS

Parents in the operatory and childrens

dental proceduresShro S, Hughes C, Mobley C. Attitudes and Preferences ofParents About Being Present in the Dental Operatory. Pediatr Dent2015;37(1):51-5.Purpose: The purposes of this study were to determine if the typeof dental procedure being performed on children had an eecton parents desire to be present in the operatory and to determineif the percentage of parents desiring to be present for their childstreatment had remained consistent over the past two decades.Materials and methods: A survey was conducted withparents of children who presented for dental appointments atthree sites: a pediatric clinic at the University of Nevada, LasVegas, School of Dental Medicine and two private practicesettings in southern Nevada. Parents or caretakers were askedto complete a three-section, 20-item survey. The sections weredemographic information, past medical and dental history, anddierent scenarios commonly associated with treatment in apediatric oce (i.e., examination and radiographs, restorativetreatment, exodontia, conscious sedation and protectivestabilization). The parents were asked whether they hadobserved the procedure before, would prefer to be present orabsent during the procedure, if their opinion would change iftheir child were struggling or crying during the procedure andif they preferred that the dentist make the decision whether theyremained in the room during the procedure. The survey was eldtested and approved by the Institutional Review Board of UNLV.Results: Three hundred and thirty-nine parents completed thesurvey. Demographic information was as follows: 73 percentfemale parent, 60 percent Hispanic, all between 25 and 40years old and have a high school education. Majority of theresponders had a household income less than $50,000 annually.More than half of the children were between 4 and 9 years oldand healthy. Seventy-nine percent of parents said that their childhad never had a bad experience with the dentist. Seventy-eightpercent of parents would prefer to be present during their childstreatment. Sixty-two percent of the parents indicated that theprimary reason they want to be present is they feel their childis more comfortable with their presence. The majority of the

parents wanted to be present for the dental procedures mentioned

above. Only 38 percent of parents would let the dentist decidewhether they should be permitted to remain during treatment.Statistically signicant ndings included the following: femaleand parents who were 31-40 years old stated that their childswell-being was the reason they wanted to be present duringtreatment. Parents with a high school education or greater chosebeing unfamiliar with the dentist as a signicant factor in wantingto be present. Married parents chose wanting to obtain moreinformation about the procedure so they could explain it to theirspouse as a factor for being present in the operatory.Conclusion: Most parents preferred to be present duringtheir childs treatment regardless of the dental procedure.More than one-third of the parents do not want the dentistto be the sole person to determine their involvement in theirchilds dental visit. Parental desire to be present duringdental treatment has not changed over the last 20 years.Reviewers comments: Parental presence is a behaviorguidance technique endorsed by the American Academy ofPediatric Dentistry. As parenting styles and societal attitudeschange, more parents want to be involved with the treatmentdecisions for their child. Parents want to be present to supportand ensure that their child is comfortable during treatment. Thisstudy also conrms that the more educated the parents are,the more likely they want to be present if they are unfamiliarwith the dentist. Parental presence during treatment can bea good practice builder but it will only work if the dentistestablishes expectations and builds trust with the parents. Thomas S. Tanbonliong Jr., DDS

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MICROBIOLOGY

PERIODONTICS

Oral microora eect on bone levels

Surgical periodontal therapy

together is better

Irie K, Novince CM, Darveau RP. Impact of the Oral

Commensal Flora on Alveolar Bone Homeostasis. J Dent Res93(8): 801-806, 2014.Background: It has long been known that the commensal oralmicroora plays a role in homeostatic regulation of alveolar bone.However, little is known regarding the underlying mechanisms ofalveolar bone loss mediated by the commensal oral microora.Methods: Histomorphometric analyses of alveolar boneloss in specic-pathogen-free (SPF) mice and germ-free (GF)mice were carried out. Immunohistochemical staining ofneutrophil markers, T-cell markers and receptor activator ofnuclear factor kappa B (RANKL) were conducted to identifythe cellular compositions within junctional epithelium (JE).Tartrate-resistant acid phosphatase (TRAP) staining for theidentication of osteoclastic cells was also carried out.Results/Discussion: SPF mice revealed increased alveolar boneloss and increased numbers of both TRAP+ osteoclastic cells andRANKL+ cells at the alveolar bone surface than GF mice. Thiswas associated with increased numbers of neutrophils, CD3+,CD4+ and interleukin-17+ cells in the JE of SPF mice comparedto GF mice. These results suggested that the host-commensal oralmicroora interactions result in the release of osteoclastogenicmolecules from the host, leading to the alveolar bone loss seenin the clinically healthy periodontium. Since RANKL has beenknown to be expressed by neutrophils and activated Th17cells, it is possible that increased alveolar bone loss causedby the commensal oral microora in SPF mice was due to theactivation of both innate and adaptive immune systems.Conclusions: An alveolar bone loss occurring in clinically healthyperiodontium is mediated, at least in part, by the immunomodulatelyeects of commensal oral microora on host cells. Takahiro Chino, DDS, MSD, PhD

Aljateeli M, Koticha T, Bashutski J, Sugai JV,Braun TM,Giannobile

WV, Wang HL. Surgical periodontal therapy with and withoutinitial scaling and root planing in the management of chronicperiodontitis: a randomized clinical trial. J Clin Periodontol2014, 41 (7): 693700.Aim: To compare the outcomes of surgical periodontaltherapy with and without initial scaling and root planing.Methods: Twenty-four patients with severe chronic periodontitiswere divided into two treatment groups, both who had modiedWidman ap surgery but only one preceded the surgery withscaling and root planing (control group). The test group hadsurgery only. Clinical parameters evaluated included probingdepths, attachment levels, bleeding on probing and radiographicevidence of bone level changes from base level to six months.Inammatory biomarkers of wound healing were also assessed.Results: Both groups showed improvement in attachmentlevels at three and six months compared to baseline. Nostatistically signicant change in biomarkers was shownbetween the groups. There was a statistically signicantimprovement in probing depth reduction in favor ofthe control group at both three and six months.Conclusion: Combining scaling and root planing withsurgery yielded greater probing depth reduction thansurgery without initial scaling and root planing.Clinical relevance: Scaling and root planing is an importantcomponent of periodontal therapy, helping to resolveinammation, reduce pockets and gain clinical attachment,even if surgery needs to be performed. Based upon thisstudy scaling and root planing might contribute to a morefavorable outcome when performed prior to surgery in theform of improved pocket depth reduction. Proponents of adirect-to-surgery approach should keep this in mind. Gerald Drury, DDS

Timothy G. Giroux, DDS

is currently the Owner &Broker at Western PracticeSales and a member of thenationally recognized dentalorganization, ADS Transitions.You may contact Dr Girouxat: wps@succeed.net or800.641.4179

Should there be a reduction in the value of

a Delta Premier only dental office?First, Lets define the problem, as there is a great deal of misunderstanding on thisissue. About four or five years ago, Delta decided that all new contracts with dentistswould include both the Premier and the PPO contract. There was no choice on thematter from the dentist. On face value, this did not seem like a big deal in practicetransitions as the assumption was that the buyer would keep all the premier patientson the higher fee schedule and that he would acquire many more new patients on thePPO fee schedule, albeit at a lower fee schedule. In fact, it seemed like a good way togrow the practice after the transition.The first time we discovered this assumption was incorrect, was upon listing a practicethat voluntarily added the PPO product to his office. He also assumed that his currentPremier patients would keep their fee schedule. He soon found that Delta was paying25 to 30 percent less on about 90% of his past Delta Premier patients. However, hefinished off that year with his highest production ever, due to the increased patientflow!

What we did not fully comprehend is that Delta has not really sold any new Premierplans for many years. Each year, the percentage of Delta Premier patients is reducedcompared to the PPO plans. Currently the percentage of Delta Premier patients isapproximately 7%. Todays current Premier Only doctors normally do not realizethat as much as 93% of their Delta Premier patients are really what we refer to asPPO Plus, meaning that Delta has agreed to pay the Premier fee schedule for the timebeing, but any change in the contract will reduce all of these patients to the standardPPO fee schedule.We have also witnessed transitions over the years where the practices gross receiptsdid suffer after the buyer was forced to take the lower fee schedule. However, since2011 when we began following this phenomenon, I can say that there is no directcorrelation to declining revenue just because of the Delta fee change issue. We recentlysold a predominately Delta practice that had 1.7 Million in gross receipts. We expectedthis practice would suffer as this practice did not need to grow their patient base withthe additional PPO patients. Six months after the sale the monthly collection numberswere actually greater!It is imperative that buyers understand this issue and find out how much of therevenues are generated by a Delta Premier only office. However, it is just one of themany variables a buyer should understand in making a good decision to purchase apractice.

Jon B. Noble, MBA

Mona Chang, DDS

John M. Cahill, MBA

Edmond P. Cahill, JD

Tech Trends

C D A J O U R N A L , V O L 4 3 , N 8

A look into the latest dental and

general technology on the market

Google Photos (Google Inc., Free)

HEALTHYDAY (McNeil-PPC Inc., Free)

Google Photos for iOS provides all users with cloud storage backupfor photos and videos on mobile devices. The application and serviceis also available for Mac, PC and Android devices. Once loggedin with a Google account, Google Photos works seamlessly in thebackground by continuously backing up all photos and videos on theiOS device through a Wi-Fi connection. When backups are complete,users are free to delete photos and videos from their camera rollson their iOS devices. All photos and videos are available to viewon the cloud through the Google Photos app. Within the GooglePhotos app, users can view their photos sorted by date or collectionsbased on photo location data. Tapping on any item enlarges it tofull screen, where users can share, edit, view info or delete the itemfrom cloud storage. Users can apply lters and use simple editingtools for their photos and videos. Google oers two storage optionsfor this service: Original and High Quality. The Original storageoption backs up and syncs photos and videos at their full resolutionand quality. This option counts against the standard storage quotafor a Google account, which is 15GB and is shared amongst otherservices such as Gmail and Google Drive. The High Quality storageoption provides unlimited storage for photos and videos that areequal to or less than 16MP or 1080p resolution. For most users, theHigh Quality option will more than suce.

HEALTHYDAY is a new app that uses crowdsourcing data to

provide real-time tracking status of health trends in any location.HEALTHYDAY works by gathering location and reports from itsusers. When the app determines its location, it asks the user simply,How are you feeling today? A color feeling indicator face can becycled through green (good), yellow, orange and red (bad). If auser is not feeling well, the app will try to determine what the useris most likely suering from using the trends of reports in the area.If the app is incorrect in determining what a user is suering from,he or she can choose from a list of common ailments that he or shethinks may be the cause of their illness. Each user report is combinedwith reports from other users to create a local dashboard, whichshows the trends and risks of allergies, colds and u in the area.An Illness Map provides locations and reports of what is goingaround in the neighborhood so that users can be on the alert whencommon illnesses are on the rise. In addition to providing real-timereports and trends in the area, HEALTHYDAY provides 30-SecondSolutions, which are helpful tips and answers to the most commonhealth questions people ask.

Hubert Chan, DDS

70 Percent of World Using

Smartphones by 2020Smartphones have become part of most peoples day-to-day livesand that trend is expected to increase over the next ve years,according to a study by Ericsson Mobility Report. Specically, 70percent of the worlds population will have a smartphone by 2020.The study went on to state that mobile trac in the rst quarter of2015 was 55 percent higher than the rst quarter of 2014 and thatby 2020, 80 percent of mobile trac will be from smartphones.Video continues to be the key growth factor, with 60 percent ofall mobile data trac forecast to be from online video by 2020,according to the study. The study also states that those who uselarger screens with their mobile devices (tablets) spend 50 percentmore time watching videos. Blake Ellington, Tech Trends editor476A U G U S T

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Hubert Chan, DDS

Adding Photo Filters Boosts Social

InteractionAdding lters to photos on social media is something amateursand more advanced photographers do, but what does it do toenhance social interaction? Yahoo! Labs released a study aimedat determining how lters aect photo engagement such as likes,comments and views. The study analyzed 7.6 million public photoson Flickr, an online photo management and sharing application,which resulted in the nding that ltered photos saw a 21 percentincrease in views and 45 percent increase in comments. Filtersthat increase contrast and correct exposure can help a photosengagement, and lters that create a warmer color temperature aremore engaging than those with cooler color eects, according tothe study. Blake Ellington, Tech Trends editor

Dr. Bob

C D A J O U R N A L , V O L 4 3 , N 8

Aging Gracefully(and Other Indignities)

The following Dr. Bob column was originally printed in the March 2010 issue of the Journal.

My knees, unlike some of

my other body parts, hadnot communicated with mefor more than eight decades.

Robert E.Horseman,DDSILLUSTRATIONBY VAL B . MINA

When I pay one of my infrequent visits

to my primary care guy, I make certainto get my $10 co-payments worth bysaving up symptoms until Im sure I haveenough to command his attention forat least 10 minutes. These are carefullyrecorded on a list I bring with me.My left knee has begun to hurt. Myknees, unlike some of my other bodyparts, had not communicated with mefor more than eight decades. I comparedthe ailing knee with its mate. Althoughthey are both the same age and appear tobe dimpled twins, the complainant hadtaken on a life of its own, either refusingto bend comfortably or threatening to flexboth ways without advance warning.After six weeks of ignoring it, I finallymanaged to accumulate a qualifyingnumber of unrelated complaints, including

a twinge in my right shoulder and two

suspicious spots on my right forearm atleast 4 microns in width. In addition,an annoying extra trip to the bathroomaround 4:30 a.m. convinced me that atleast one or two of these symptoms confirmthe presence of a fatal disease requiringsurgical intervention immediately. Timeto shell out the $10 co-pay.My instinctive distrust of generalanesthesia was intensified by theprobability of the operating surgeonassigned to save my life being revealedas a head case on the verge of goingpostal from stress and fatigue. Youneed to make an appointment, I toldmyself. I did the following spring.An overhead wide-angle shot of asurgical amphitheater overflowing withstudents and resident doctors forms clearlyA U G U S T 2 015 477

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DR. BOBC D A J O U R N A L , V O L 4 3 , N 8

in my mind. Gathered from as far away as

Rochester, the assemblage leans forward inhushed reverence to witness my surgeonslegendary expertise. I had just becomeaware of two morgue attendants standingexpectantly in the background beside theirgurney when I hear a female voice announce, Robert, you may come in now.I try to respond in kind by attemptingto read her name tag pinned to her blousejust south of her left clavicle, but realizethat staring any longer to make out thewords would not be in my best interests.Laying aside the article I had been readingin Womans Day on how to cope withthose pesky postpartum stretch marks, Itrail after the paisley-topped assistant intothe inner sanctum. Young enough to bemy granddaughter, she is preternaturallycheerful as she confides that we willpause for a moment to weigh me.At the end of the hall is the scale,impossible to circumvent. The drill isalways the same and her buoyancy isill-suited for the occasion. Hop on, shetrills cheerfully. Every time I have evermounted one of these doctor scales it isobvious the patient before me could nothave weighed more than 110 pounds.There follows a deliberate, prolongedhumiliation during which the weights areslowly advanced along their tracks almostto the end before balance is achieved. Myshoes weigh at least five pounds each, youknow, I always offer, feeling this shouldbe taken into account as a truer indicationof my poundage. I could be wearing afull-length raccoon coat, pockets loadedwith enough lead weights to anchor theQE2 and the results would be carefullyrecorded in my chart. Technically, oneshould be weighed in the buff. If nothingelse, the procedure would add interest toan otherwise dull day at the office. If aninaccuracy of this magnitude is tolerated,the requisite recording of my vitals thatfollows is subject to plus or minus 35478A U G U S T

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Whats the matter with

your knee? he asks.Well, duh! At $10 I haveto do my own diagnosis?percent errors and are meaningless exceptto satisfy blank places on the chart.It seems under-the-tonguethermometers are an anachronism. Ahand-held electronic probe is insertedthree inches into my ear, beeps once andimmediately withdrawn. I assume this isa rejection because of the wax buildup,but Paisley dutifully notes the 98.6 onmy chart and takes my blood pressure.Blood pressure taken in an examinationroom automatically initiates the whitecoat syndrome and elevates itself to nearfatal limits. I also believe if I hold mybreath, close my eyes and roll my eyeballsupward in their sockets, then focus onarbitrary numbers like 120 and 75, I canachieve any reading I please commensuratewith my age. Or better yet, some kidabout 25 who has matured in every wayexcept for calling everybody Dude!and wearing a baseball cap incorrectly.Paisley smiles benignly at me. Werethe room to be suddenly bathed inultraviolet light, a little thought bubblewould appear over her head containingthe words What a porker! In any event,Paisley is satisfied with my BP, thinking,not bad for a geezer with one foot in.She departs to fetch the doctor,taking my 2-inch thick folder withher lest I sneak a peak at my ownrecords that I couldnt read anyway,written as they are in Physicianese!Modern medicine has streamlined thewhole medical appointment experienceto the point where the doctor is thelast person encountered. When I wasyounger, the next step would be the

entrance of the doctor, an older man

radiating compassion and wisdom, sortof like my grandfather, only richer.In time (this is Doctor Time, differentfrom Patient Time), the doctor breezesin. A substantial part of my wardrobe isolder than he. He gets right to the point,the meter is running. Whats the matterwith your knee? he asks. Well, duh! At$10 I have to do my own diagnosis?It hurts when I do this, I explain,flexing my left leg gingerly.Then dont do that. His eyesgrow pensive. How long?Six weeks. He palpates the joint in adoctorly manner. A stretched ligament ortendon, he says, conserving unnecessarywords as if texting me. Nothing toworry about. Take a while to disappear.Couple of Advil or Aleve are OK.But, I It is too late. Obviously,administering extreme unction to myknee is premature and the problemis too intricate and inconsequentialto warrant recapitulating.You need a flu shot and a pneumoniashot, he states. Take this form tothe lab. See you in two weeks.Hes out the door and I am left sittingon the crinkly paper-covered table,as my list of assorted ailments fluttersto the floor. Left knee, CHECK.What a nice man! Not once did hemention the fact that at my age it wouldbe unrealistic to expect anything lessthan a yard-long grocery list of physicalwoes. Maybe Ill come back next fall aftera summer of reckless hedonism. I shouldhave a list to reckon with by then.

Were taking your requests

If you have a favorite Dr. Bob columnyou want to see again, email PublicationsSpecialist Andrea LaMattina at andrea.lamattina @ cda.org. We will oblige byreprinting those requested favorites interspersedwith any new Dr. Bob submissions.

Your convention.Your rst look.

With approximately 400 companies showcasing their latest products and services,the exhibit hall at this years convention is the perfect place to see and try excitinginnovations in dentistry for yourself. CDA Presents The Art and Science of Dentistry.Yeah, this is your convention.